Neck pain

Patient presents with a

painful neck

Red Flags

Consider admission/
Urgent referral

Non-Specific neck pain Neck pain with

radicular/neurological
signs

Management
Management

If no improvement
consider community
physiotherapy

If no improvement
consider referral to
Specialist
R

Published: 16th April 2015 Valid until: 31st October 2016

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A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.
Neck pain

2 Red Flags
Quick info:
History of or suspected malignancy:
• investigate and refer as appropriate
• consider red flags of unexplained weight loss, night pain and high inflammatory markers.
Suspected fracture, dislocation, or infection:
• refer to ED
Acute Cervical Myelopathy or multi-level neurological signs:
• refer to neuro-surgery
Vascular disorders of the carotid or vertebral arteries:
• refer to the vascular service
Suspected inflammatory condition:
• investigate and refer to Rheumatology

6 Management
Quick info:
Management:
• Reassure patient
• Recommend simple range of movement exercises
• Encourage maintaining function
• Consider analgesia
• Self Help/Patient Information

7 Management
Quick info:
Management:
• Consider medication management as outlined in supporting information.
• Only consider x-ray if clinically indicated

Published: 16th April 2015 Valid until: 31st October 2016

Page 2 of 2
A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.
MSK SERVICES PATHWAY - SHOULDER PATHOLOGY
GPs to follow guidance offered within this pathway and where relevant refer using
Ardens templates and within remit of CCG Restricted and Not Routinely funded policy.

RED FLAG

• Septic arthritis • Fractures

Diagnosis to • Dislocations • Tumours
monitor • Visceral referred pain • Neurological lesion
• Acute rotator cuff tear

Medical Professionals seeing patients with

History & MSK complaints in primary care should be
Symptoms trained in assessing for alarming features and
red flags in all patients.

Injury Consider admission/urgent referral

ASSESSMENT & DIAGNOSIS OF OTHER CONDITIONS

Adhesive capsulitis/contacted shoulder

Subacromial pain syndrome

Glenhumeral OA/18 AC joint

Rotator cuff

Instability (non-acute)

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RED FLAG SCREENING: SPECIFIC FOR SHOULDER PATHOLOGY
History & Medical Professionals seeing patients with MSK complaints in primary care should be trained in
Symptoms assessing for alarming features and red flags in all patients.

CONSIDER ADMISSION/URGENT REFERRAL IF:

History of, or suspected malignancy investigate and refer as appropriate.
SYMPTOMS SUGGESTIVE OF TUMOURS (PRIMARY OR METASTATIC):
• PMH of cancer - Bony metastasises develop in 2/3 of patients with cancer -
Mostly prostate, breast, kidney
• Unexplained weight loss
• Non-mechanical night pain
• Deep, intense pain
• Pain worse at night
• Fever
• Mass presence
• Lymphadenopathy
If History of cancer, needs to be referred urgently for specialist assessment in line with 2 week
fast track cancer pathway.

SYMPTOMS SUGGESTIVE OF INFECTION OR SEPTIC ARTHRITIS:

• Risk factors for sepsis include: Comorbidities of RA, or OA, prosthetic joint, low
socioeconomic level, dia betic, alcoholism, previous intra-articular joint injection, IV use
• Constant pain
• Sudden onset, red, hot, pyrexia or red-hot joint
• High inflammatory markers
• Systemic symptoms
• Fever, not always present
Suspected inflammatory condition, investigate and refer to Rheumatology - see Rheumatology
pathway.
SYMPTOMS SUGGESTIVE OF ACUTE SHOULDER JOINT FRACTURE/DISLOCATIONS:
• Trauma
• Pathological fracture (OP, Paget’s, multiple myeloma, PMH Ca)
• Neurovascular deficit
• Deformity
• Muscle wasting
Suspected fracture, dislocation, refer to ED
SYMPTOMS OF VISCERAL REFERRED PAIN:
• Shoulder pain from visceral origin can be secondary to: heart, lung. Gall bladder and liver,
upper GI and diaphragm
• Will be associated with additional; systemic symptoms, such as respiratory symptoms, SOB,
chest pains, fever, sweats, vomiting
Referral to appropriate speciality-inform referring GP
SYMPTOMS OF NEUROLOGICAL LESION:
• Usually without trauma the presence of:
• Sporadic attacks of neuralgic pain
• Unexplained muscle wasting
• Significant motor or sensory deficit
• May not be specific to one muscles group

Suspected neurological lesion refer to neurologist.

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RED FLAG SCREENING: SPECIFIC FOR SHOULDER PATHOLOGY
Injury CONSIDER ADMISSION/URGENT REFERRAL IF:
• Recent trauma to shoulder
• Pain may or may not be present
• Muscles wasting
• Reduced function
• If high severity of pain and disability could mean possible large cuff tear therefore consider
orthopaedics for surgical referral (following clinical assessment)
• Deformity- severe pain in any patient with known metabolic bone disease
• Neurovascular deficit
• Weakness- if after rotator cuff tear
• Infection- look for signs of infection- hot swollen joint
• Acute distal biceps rupture, urgent referral to Orthopaedics/A&E/Fracture
• Traumatic shoulder dislocation if unreduced: ED – Reduced: refer to soft-tissue clinic
• ACJ dislocation: Refer to Soft-tissue clinic or fracture clinic. Any urgent dislocations should be
referred to ED and if no fracture, refer to soft tissue clinic. If fracture discovered refer to
fracture clinic
• Acute Rotator cuff tear refer to soft tissue clinic as they can scan at this point
• If not sure – can always discuss a patient with a consultant in fracture clinic

DIAGNOSIS: ADHESIVE CAPSULITIS/CONTRACTED SHOULDER

TYPE OF
GUIDELINES
INFORMATION
Background • Adhesive Capsulitis or Contracted (Frozen) Shoulder is a combination of shoulder pain and
information stiffness that causes sleep disturbance and marked functional disability
• The condition can run a prolonged course, and symptoms usually take between one to three
years to resolve. In some cases, it does not resolve completely.
• Contracture is such a striking feature of the condition that the term ‘Contracted shoulder’ is
now used to describe this condition
• The aetiology is unclear
• Most common in people aged 40 and 60
• Can occur secondary to:
• Prolonged immobilisation- such as stroke
• Diabetes
• Females > males
CLINICAL FINDINGS: There is no agreed diagnostic reference standard
Stages of the condition: A true Contracted Shoulder is categorised into either 3 phases:-
• Pain predominant phase (early painful stage) - progressive stiffening and loss of motion in
the shoulder with increasing pain on movement
• Stiffness predominant phase (later stage) - decrease in pain but range of movement remains
restricted
• Recovery phase - range of movement improve

Subjective • Screen for red flags

History • Most cases occur in patients aged between 40-60 years of age, in women > men, and could
affect up to 1 in 20 people.
• The exact cause is not fully understood, although it appears to be more common in people
with certain health conditions such as diabetes.
• There is a gradual onset of arm pain
• Unable to lay on the affected side
• Restriction of movements notably including elevation and external rotation
• The condition runs a distinct course

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DIAGNOSIS: ADHESIVE CAPSULITIS/CONTRACTED SHOULDER
TYPE OF
GUIDELINES
INFORMATION
Examination • The principal diagnostic test is passive external rotation which is restricted in Contracted
findings Shoulder (but also in other conditions). It is recommended that external rotation be tested
with the patient’s elbow at their side and that trunk rotation is limited by the tester with the
tester’s shoulder behind the patient’s scapula to detect scapular retraction.
• A finding of restricted passive external rotation should be corroborated by history (screening
for substantial trauma/serious disease), X-ray exam (which can exclude the other causes of
restriction) and palpation (screening for gross crepitus)
• Differential diagnosis between Contracted Shoulder and the impingement-type disorders
does cause some confusion in practice. Specifically, standard tests for impingement are
positive in the pain-predominant phase, because they involve stretching the joint capsule. A
simple diagnostic approach is to regard the signs of Contracted Shoulder as taking primacy
over signs of impingement in terms of diagnosis and management.
• Observe for muscle wasting, alignment
• Bony palpation- assessing for TOP, warmth swelling
• May be tenderness over anterior joint line
• Reduction in both active and passive range, in particular lateral rotation
• May have a capsular pattern of restriction
• Assess power- often no weakness; however pain can inhibit muscle strength in early stages
of condition

Investigations • If diabetes is suspected in a patient with a stiff shoulder with which the clinical pattern is that
of contracted shoulder, tests should be done to evaluate for diabetes
• GP rule out diabetes and thyroid disorders
• GP or APP to do X-ray AP and axial to exclude other pathology (GH OA, Posterior
dislocation), as per BESS/BOA 2015 recommendations
• AP & Axial views are recommended

Conservative REFER THROUGH TO PHYSIOTHERAPY IN THE FIRST INSTANCE:

management
• Explain the usual timescale of Contracted Shoulder: It will spontaneously resolve with
reduction of stiffness (although the full range of motion may not be fully recovered) but this
will usually take months to years. Reassurance
• Advise avoidance of movements which aggravate the pain in the early, painful phase
(e.g. overhead activities, vigorous stretching) but advise the person to continue a regular
range of movement. Pacing and self-management.
• Ensure adequate analgesia, particularly in the early, painful phase: Paracetamol with or
without codeine, or an oral NSAID e.g. ibuprofen). Consider which drug has a more
favourable balance of benefits and risks for the person. If there is no early benefit from oral
NSAID, discontinue its use. Refer r back to GP for analgesia management
• Physiotherapy if the person is able to tolerate movement of the affected shoulder. Ensure
adequate analgesia is provided
IN THE EARLY PAIN PREDOMINANT PHASE:
• Provide advice and education
• Advice re. application of heat and/or cold packs
• Gentle exercises and postural correction
• Mobilisation if appropriate
• Use a regional or validated outcome measure (at the least PSFS and VAS +/- DASH,
Oxford Shoulder score etc.).

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DIAGNOSIS: ADHESIVE CAPSULITIS/CONTRACTED SHOULDER
TYPE OF
GUIDELINES
INFORMATION
Conservative STEROID INJECTIONS
management
• Consider an intra-articular (glenohumeral) corticosteroid injection early in the course of
contracted shoulder if there is no, or slow, progress with conservative treatment. Via GP in
Primary Care or referral to Secondary Care if not available by GP
Do not refer for injection if:-
• The person has already had an intra-articular corticosteroid injection from an experienced
practitioner, with minimal or no benefit
• The person has had one injection in the same shoulder in the course of a year either blind
injection or USGI
• The pain has settled and stiffness is the predominant feature
• Steroid injection is contraindicated (e.g. infection, sensitivity to local anaesthetic etc.)
• If referring patient with DM ,ensure good diabetic control HB1AC<69
PHYSIOTHERAPY IN THE LATER STIFFNESS PREDOMINANT PHASE:
• Active ROM
• Stronger mobilisation
• Functional strengthening (avoiding impingement) with good scapular stability/posture
• Cord and pulleys If appropriate
• Functional rehabilitation
PROGNOSIS
• Poorer prognosis is associated with older age, diabetes, severe and recurrent symptoms at
presentation and those patients with associated neck pain

Referral on for • If the diagnosis is uncertain

orthopaedic • If there is an inadequate response to 3 months of physiotherapy
opinion: • If Opioid analgesia is being considered
• If arthroscopic release or manipulation under anaesthetic (MUA) are being considered.

DIAGNOSIS: SUBACROMIAL PAIN SYNDROME

TYPE OF
GUIDELINES
INFORMATION
Background • Subacromial pain syndrome is a term used to describe rotator cuff lesions in all stages from
information degeneration through to complete tears
• The pain comes from the subacromial space of the shoulder, which contains the rotator cuff
tendons and the subacromial bursa, and NOT from the glenohumeral joint
• No specific age although age may give some indication of its likely stage - see Neer and
Welsh’s (1977) classification
• In those under 35 years old this can be linked and secondary to instability.
• May be insidious or related to a specific incident/trauma
• The treatment aim for subacromial pain is to ‘improve pain and function’. Success is defined
individually with patients to include the degree of improvement needed, and the level of
residual symptoms that might be acceptable. Outcome depends on starting level of
symptoms, patient demographics and expectations, as well as personal circumstances

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DIAGNOSIS: SUBACROMIAL PAIN SYNDROME
TYPE OF
GUIDELINES
INFORMATION
Subjective • Screen red flags
information • Pain is experienced in the shoulder / deltoid region and may radiate into the arm, it may be
aching and / or sharp in nature
• It may be aggravated by overhead activities and at night when lying on that side
• May describe a painful arc
• There may be crepitus and if secondary to instability painful clicking, a feeling of heaviness or
a “dead arm”

Examination May include:

findings
• Muscle wasting of supraspinatus in chronic SAP
• Assess cervical and thoracic spine
• Altered scapulohumeral rhythm may be present
• Painful arc may be present with elevation (flex or abduction) and if a painful arc is positive,
SIS is very likely.
• There is possible limitation of elevation, MR and horizontal Adduction
• Passive MR may be limited
• Resisted muscle testing pain implicates the cuff and cuff tears are associated with weakness
• Assess instability tests if felt, to be contributing to subacromial pain
• Consider contractile, cuff and impingement tests ( Full can test, - drop arm, lift off, Neers and
Hawkins Kennedy tests, painful arc )
• Must differentiate between full thickness cuff tears

Investigations AP & Axial may be required if poor response to treatment

• X-rays are of very limited value in the early stages
• Age 40-60 physio to request AP/axial X-rays
• Radiographs enable visualisation of calcific tendinitis, acromial morphology, subchondral
cysts or sclerosis, osteoarthritis of the acromioclavicular joint and the acromiohumeral
interval.
• Magnetic resonance imaging is not normally indicated in SIS
• Ultrasound may be of benefit for differential diagnosis and can identify full thickness tears of
cuff if suspected
MRI is at the secondary care consultant’s discretion if not responding to conservative treatment

Conservative The majority of patients can be managed conservatively.

management
• Advice: Initially relative but not absolute rest should be recommended together with the
avoidance of overhead and other aggravating activities
• Ensure adequate analgesia: The benefits of a short course (7-21 day) course of NSAIDs in
appropriate patients are likely to outweigh the risks
• Steroid injection: Steroid injections benefit SIS in the short term. It is suggested that they
are best used to facilitate rehabilitation and that unless pain is severe a several-week trial of
more conservative treatment should precede their use. Consider x 1 into sub-acromial space
- if no tear in patients receiving physiotherapy

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DIAGNOSIS: SUBACROMIAL PAIN SYNDROME
TYPE OF
GUIDELINES
INFORMATION
Conservative Physiotherapy:
management
• Explanation of the nature of the problem and treatment rational
• If there is significant pain and NSAID’s have not been prescribed, this option should be
discussed with the appropriate medical practitioner. Refer back to GP for adequate analgesia
• Advice regarding the use of cold packs may be useful in reducing the pain and inflammation
of SIS and to settle irritation post exercise. There is insufficient evidence to support the use
of heat, but this may be useful in addressing secondary protective muscle spasm, i.e. in
upper fibres of trapezius
• Posture improvement
• Passive mobilisation of the upper quadrant (shoulder, cervical & thoracic spines) as
necessary and according to standard principles (Maitland, 1991)
• A programme of exercises to restore scapular stability, shoulder range of movement, strength
and scapulohumeral rhythm (for 12 weeks)

Referral on for • If the diagnosis is uncertain

orthopaedic • The evidence states that if there is an inadequate response to 6 - 12 weeks of best evidence
opinion conservative treatment as described above
• If subacromial decompression or further investigations are being considered
• Consider CCG prior approval form and that all conservative treatment has been considered/
trialled

DIAGNOSIS: GLENOHUMERAL OA / 18 AC JOINT PATHOLOGY

TYPE OF
GUIDELINES
INFORMATION
Background Acromioclavicular OA is more common than glenohumeral joint OA
information

Subjective SUBJECTIVE:
history
AC joint OA
• Screen red flags
• Pain over shoulder- typically superior to anterior shoulder
• Patients can often point to area of specific pain
• Pain provoked by arm reaching across body (golf swing, overhead lifting in abduction
Glenohumeral OA
• Screen for red flags
• Typically in older people or after trauma in younger people
• Pain that is worse on movement
• Less specific description of pain, vague dull aching
• Describe stiffness in the shoulder
• Reduced function

Examination • May have wasting of muscles if OA coexists with rotator cuff disease
findings • Difficulty with self-care
• Stiffness of joint both active and passively

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DIAGNOSIS: GLENOHUMERAL OA / 18 AC JOINT PATHOLOGY
TYPE OF
GUIDELINES
INFORMATION
Investigations If stiffness present, x-ray is the only way to exclude other causes of joint stiffness such
as inflammatory arthritis, OA, fractures, serious pathology of bone.
• GP to do X-ray AP View and Axial as standard
• If X-ray shows arthritic changes, with gross limitation of function refer directly to Orthopaedic
Surgeon
• If minor arthritic changes: Consider analgesia, possible referral through to physiotherapy
• Community clinic review for shared decision making with ESP and Orthopaedic Surgeon if
diagnosis unclear or significant functional loss with minimal x-ray changes

Conservative SUBJECTIVE:
management
AC joint
• Most people will respond to rest and simple analgesia
• Advice
• Avoidance of aggravating positions and movements
• Corticosteroid injection
• No or temporary response to Physiotherapy and injection - 6-12 weeks refer to Orthopaedic
surgeon
Glenohumeral
• Advice on diagnosis, prognosis, refer patient to NICE/NHS choice websites
• SDM, include patient in planning of treatment, consider;
• Analgesia, topical creams
• Refer to occupational therapy if significant problems with self-care

Referral on for • Early OA reported on X-ray

orthopaedic • Refer on those with significant joint OA with significant pain and disability despite appropriate
opinion treatment
• ESP/advanced practitioner/physiotherapist to have some knowledge of possible surgical
options
• BESS/BOA patient care pathway
• http://www.bess.org.uk/application/files/2314/8127/3403/Shoulder_Elbow-2016-Thomas
-203-14.pdf

DIAGNOSIS: ROTATOR CUFF PATHOLOGY

TYPE OF
GUIDELINES
INFORMATION
Background Subacromial shoulder pain from rotator cuff pathology, including, tendinopathy, calcific tendinitis,
information and rotator cuff tears accounts for up to 70% of all new shoulder pain problems. The rotator
cuff tendons can be either intact or torn. Tendons can tear acutely due to injury, or due to
degeneration. A tear that does not extend all the way through the tendon is called a partial
thickness tear. The treatment aim for rotator cuff pathology is to ‘improve pain and function’.
Success is defined individually with patients to include the degree of improvement needed, and
the level of residual symptoms that might be acceptable. Outcome depends on starting level of
symptoms, patient demographics and expectations, as well as personal circumstances.

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DIAGNOSIS: ROTATOR CUFF PATHOLOGY
TYPE OF
GUIDELINES
INFORMATION
Subjective • Screen for red flags
History • Pain is experienced in the shoulder / deltoid region and may radiate into the arm, it may be
aching and / or sharp in nature
• It may be aggravated by overhead activities and at night when lying on that side
• May describe a painful arc
• There may be crepitus and if secondary to instability painful clicking, a feeling of heaviness
or a “dead arm”

Examination May include

findings
• Muscle wasting of supraspinatus in chronic pathology
• Assess cervical and thoracic spine
• Altered scapulohumeral rhythm may be present
• Painful arc may be present with elevation (flex or abduction)
• There is possible limitation of elevation, MR and horizontal Adduction
• Passive MR may be limited
• Resisted muscle testing pain implicates the cuff and cuff tears are associated with weakness
• Assess instability tests if felt, to be contributing to pain
• Consider contractile, cuff integrity and impingement tests ( Full can test, - drop arm, lift off,
Neers and Hawkins Kennedy tests, painful arc)
• Must differentiate between full thickness cuff tears (acute/degenerative tears)

Investigations • < 60 years AP view, > 60 years AP and axillary view

• US can identify full thickness tears of rotator cuff if suspected
• MRI can identify full thickness tears of rotator cuff if suspected, to be used at the consultant
discretion
• Clinical reasoning/learning tool/discussion:
• Depth of tear- No correlation to physiotherapy outcome. Orthopaedic team will use depth of
tear to determine type of surgery if not responding to conservative measures.
• Guide as follows:
1/3 would consider decompression
2/3 would consider repair
• Anterior edge full thickness tear terminology: is the anterior edge of the involved tendon - not
full thickness of the whole tendon - for conservative measures initially.

Conservative Referral through to physiotherapy:

management
• Education, rest, analgesia (refer to GP for adequate analgesia)
• 80% of patients are reported to improve with conservative management
• Appropriate structured physiotherapy with goal setting for 6 to 12 weeks to include postural
correction and motor control retraining, stretching, strengthening of the rotator cuff and
scapula muscles and manual therapy
• If a partial or full thickness tear is reported on US scan/MRI discuss the possibility of a local
injection with the patient and the aims of the injection to reduce pain and improve function.
Inform the patient that an injection could delay surgery if this were required and could
potentially affect the outcome of any surgical intervention- shared decision making
conversation (SDM document in patient notes)
• There is some debate regarding steroid injections in patients with partial and full thickness
tears within local secondary care and BESS/BOA guidance. This could be discussed with
shoulder consultant at local clinic or through advice and guidance (GP)
• Do not do repeated injections into the subacromial space in patients where surgery may be
considered as this may cause tendon damage
• Over 75 years old may want to consider injection and rehabilitation as often cuff quality not
amenable to surgical intervention

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DIAGNOSIS: ROTATOR CUFF PATHOLOGY
TYPE OF
GUIDELINES
INFORMATION
Referral on for • ALL acute traumatic tear should be referred for orthopaedic opinion (occurred in last 6 weeks)
orthopaedic • Full or partial degenerative tears that have had no response to appropriate conservative
opinion management (6-12 weeks of physiotherapy)
• Subacromial shoulder pain and profound weakness with ultrasound or MRI findings
indicating a full thickness rotator cuff tear after adequate and appropriate conservative
treatment
• Consider referral for shared decision-making following BESS Guidelines: sub-acromial
decompression or repair
• Continue with physiotherapy for cuff tears even when listed for surgery
• X-ray shows arthrogenic changes referral for orthopaedic surgical consideration
• BESS/BOA patient care pathway below
• http://www.bess.org.uk/application/files/2914/8127/3402/
• Subacromial_Shoulder_Pain.pdf
PROGNOSIS
Cuff tears in over 75’s generally not repairable or repair has high failure rate, but other
interventions such as sub-acromial decompression are effective. If conservative treatment fails
and the patient is still symptomatic refer to secondary care consultant
Consider formal smoking cessation program prior to referral for cuff repair.

DIAGNOSIS: INSTABILITY (NON ACUTE)

TYPE OF
GUIDELINES
INFORMATION
Background Instability of the shoulder joint is a broad term for hypermobility including subluxation and
information dislocation. Laxity can exist without instability or they may coexist. Shoulder instability typically
occurs in children, younger adults < 35.

Subjective • Screen for red flags

history • Onset- often traumatic but may present with multiple recurrence that are atraumatic
• Typical mechanism of injury is position of external rotation and abduction
• Feeling of instability
• Pain/symptoms vague
• May report ‘dead arm’ symptoms on occasion
• Possibly report functional limitations in external rotation and abduction activities

Examination • Observe, may have deformity

findings • May have space below acromion
• Muscle wasting or spasm
• Functional loss
• May have tenderness on palpation of soft tissue
• Assessment for loss of active and passive movement as tolerable

Investigations • Consider AP and Axial Shoulder

• Recurrent dislocations- at the discretion of a Specialist Orthopaedic Surgeon

Conservative Non acute or recurrent dislocations:

management
• Atraumatic dislocations for 3-12 months physiotherapy
• Advice on provocative positions. Strengthening and functional rehabilitation
• Multi-directional case by case – try physiotherapy in the first case

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DIAGNOSIS: INSTABILITY (NON ACUTE)
TYPE OF
GUIDELINES
INFORMATION
Referral on for • Traumatic First time dislocation (reduced) if referred through triage should be treated via the
orthopaedic soft tissue shoulder clinic referral pathway Traumatic Recurrent Instability (reduced) – routine
opinion referral to orthopaedic surgeon

DIAGNOSIS: CALCIFICATION TENDINOPATHY

TYPE OF
GUIDELINES
INFORMATION
Background Calcific tendinopathy is a disorder of the shoulder of unknown etiology. It is characterised by the
information formation of deposits of calcium crystals in one or several of the rotator cuff tendons, leading to
pain and dysfunction. Many cases resolve spontaneously or with conservative management

Subjective Several systemic diseases are associated with an increased risk of calcification, such as
history gout, hypercalcemia of any cause, and various rheumatic diseases
The chief patient complaints to expect in calcific tendinopathy are:
1. Night pain, causing loss of sleep.
2. Constant dull ache
3. Pain increases considerably with AROM
4. Decrease in ROM, or complaint of stiffness
5. Radiating pain up into the suboccipital region, or down into the fingers

Examination Since imaging is the only way to diagnose calcific tendinopathy, physical examinations
findings will seek to rule out a condition rather than to rule in a condition.
• Observation-check bilaterally for swelling, atrophy or scapular movement that will indicate
compensation for decreased humeral movement.
• Palpation-attention to any swelling, temperature difference, point tenderness.
Most specifically, the supraspinatus tendon, as it is the most commonly affected[7].
The infraspinatus, teres minor, subscapularis, and biceps tendons are also involved and
follow in incidence in the afore-mentioned order[1].
• Neuro and cervical screen
• AROM and PROM-pain and decreased ranges may be present in any, or all planes
(depending on tendon(s) involved). Observe end feel, may be empty 2˚ to pain.
• MMT’s-may demonstrate decrease from contralateral side or be limited by pain.

Investigations • X-ray - As Calcific tendinopathy is a soft tissue injury that can only be conclusively diagnosed
via imaging, it is important to rule out other shoulder pathologies. Imaging will provide
definitive proof of calcific build-up through what appear to be “bone spurs”.
• USS - An ultrasound image of the area is also advised, as this will rule out or rule in any
differential diagnosis of soft tissue injuries such as a rotator cuff tear

Conservative • Physiotherapy including PROM/AAROM/AROM, capsule stretching and isometric activation

management of the affected rotator cuff musculature. Grade II-IV glenohumeral anterior-posterior and
caudal glides should also be used when applicable restrictions are found.
• If calcification in tendon on ultrasound scan – physiotherapy
• If calcification in tendon on X-ray – physiotherapy + injection

Referral on for • Calcification on X-ray not improved by physiotherapy and injection – USGI may be
orthopaedic considered
opinion

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MSK SERVICES PATHWAY - ELBOW PATHOLOGY
GPs to follow guidance offered within this pathway and where relevant refer using
Ardens templates and within remit of CCG Restricted and Not Routinely funded policy.

RED FLAG

• Septic arthritis • Fractures

Diagnosis to • Dislocations • Tumours
monitor
• Neurological lesion

Medical Professionals seeing patients with

History & MSK complaints in primary care should be
Symptoms trained in assessing for alarming features and
red flags in all patients.

Injury Consider admission/urgent referral

ASSESSMENT & DIAGNOSIS OF OTHER CONDITIONS

Tennis or Golfer’s elbow

OA of the Elbow Joint

Loose Body

Nerve Entrapment at the Elbow

Unstable Elbow

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RED FLAG SCREENING: SPECIFIC FOR ELBOW PATHOLOGY
History & Medical Professionals seeing patients with MSK complaints in primary care should be trained in
Symptoms assessing for alarming features and red flags in all patients.

CONSIDER ADMISSION/URGENT REFERRAL IF:

History of, or suspected malignancy investigate and refer as appropriate.
SYMPTOMS SUGGESTIVE OF TUMOURS (PRIMARY OR METASTATIC):
• PMH of cancer- Bony metastasises develop in 2/3 of patients with cancer mostly prostate,
breast, kidney, lung, thyroid, myeloma
• Unexplained weight loss
• Non-mechanical night pain
• Deep, intense pain
• Pain worse at night
• Fever
• Mass presence
• Emergence of bony lump
• Lymphadenopathy
• Atypical presentation
If History of cancer, needs to be referred urgently for specialist assessment in line with 2 week
fast track cancer pathway.

SYMPTOMS SUGGESTIVE OF INFECTION OR SEPTIC ARTHRITIS:

• Risk factors for sepsis include: Comorbidities of RA, or OA, prosthetic joint, low
socioeconomic level, diabetic, alcoholism, previous intra-articular joint injection, IV use
• Constant pain
• Sudden onset, red, hot, pyrexia or red-hot joint
• High inflammatory markers
• Systemic symptoms
• Fever, not always present
Infections refer to ED.
Suspected inflammatory condition, investigate and refer to Rheumatology – see Rheumatology
pathway.
SYMPTOMS SUGGESTIVE OF ACUTE SHOULDER JOINT FRACTURE/DISLOCATIONS:
• Trauma
• Pathological fracture (OP, Paget’s, multiple myeloma, PMH Ca)
• Neurovascular deficit
• Deformity
• Muscle wasting
Suspected fracture, dislocation, refer to ED

Injury CONSIDER ADMISSION/URGENT REFERRAL IF:

• Suspected fracture- consider pathological fracture with minimal trauma in patients with
Paget’s, Gauchers disease, osteoporosis, PMH of CA, multiple myeloma, osteogenesis
imperfecta
• Significant trauma
• Dislocation
• Distal Bicep/triceps Tendon Rupture urgent referral to Orthopaedics/A&E/Fracture Clinic
based on clinical presentation

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DIAGNOSIS: TENNIS OR GOLFER’S ELBOW
TYPE OF
GUIDELINES
INFORMATION
Background LATERAL EPICONDYLITIS/TENDINOPATHY
information
Lateral epicondylitis is also known as tennis elbow. It has a high prevalence of between 1-3%
of the population, with an incidence in general practice of 4-7 consultations per 1000. The peak
onset is between 40-50 years. Women and men are equally affected. The dominant arm is
affected in 75% of people.

Subjective • Lateral elbow and upper forearm pain

History • Typically pain of gradual onset, worsened with use of affected muscles
• Precipitating factors: repetitive movements involving forearm muscles, acute injury,
occupational or recreational activities that may provoke pain
• Need to exclude pain from other sources: cervical spine, elbow arthropathy, radial tunnel
syndrome. Shoulder, neurological symptoms

Examination • Pain on resisted wrist extension with elbow fully extended

findings • Pain with forced wrist flexion with elbow extended
• Pain with resisted extension of the 3rd finger with elbow extended
• Pain have some pain with active and passive movements at the elbow- but can also be normal
• Localised tenderness over and distal to the lateral epicondyle
• Possible reduction in grip

Investigations • Investigations often only necessary when considering a differential diagnosis

• X-ray appropriate IF suspecting fracture
• MRI or US scan may be performed at discretion of consultant in secondary care

Conservative • Consider analgesia and NSAIDs.

management • Advise joint care, ice treatment
• Exercise therapy: resistance exercises can result in reduced pain and improved function.
Programmes that concentrate on eccentric and concentric exercise are resorted to be effective
• Evidence suggests 12 weeks of exercise therapy
• Injection: In the case of refractory symptoms, only one corticosteroid injection may be
considered
Referral on for • If no improvement after 12 weeks refer to orthopaedic surgeon
orthopaedic
PROGNOSIS:
opinion:
• Usually self-limiting
• Duration is between 6 months and 2 years
• 20 % of people still report symptoms after 1 year

Background MEDIAL EPICONDYLITIS/TENDINOPATHY

information
Medial epicondyle pain is often referred to as golfer’s elbow or carpi radialis tendonitis/
tendinopathy. It is less common than lateral elbow pain

Subjective • Medial elbow pain and tenderness of the flexor muscles

History • Pain typically of gradual onset, worse with use of the effected muscles
• Precipitating factors: repetitive movements involving forearm muscles, acute injury,
occupational or recreational activities that may provoke pain
• Need to exclude pain from other sources: cervical spine, elbow arthropathy, cubital tunnel
syndrome. Shoulder, neurological symptoms

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DIAGNOSIS: TENNIS OR GOLFER’S ELBOW
TYPE OF
GUIDELINES
INFORMATION
Examination • Pain on wrist flexion and pronation
findings • Can have pain on active and passive movements at the elbow, but often this can be normal
• Localised tenderness over and distal to medial epicondyle
• Possible intermittent or on occasion constant, numbness or tingling radiating into the 4th and
5th fingers, exacerbated by elbow flexion or tapping over the nerve (close proximity to cubital
tunnel

Investigations • Investigations often only necessary when considering a differential diagnosis

• X-ray appropriate IF suspecting fracture
• MRI or US scan may be performed at discretion of consultant
• NCS where nerve entrapment or cervical spine involvement suspected

Conservative • Advise joint care, ice treatment

management • Exercise therapy: resistance exercises can result in reduced pain and improved function.
Programmes that concentrate on eccentric and concentric exercise are resorted to be effective
• Evidence suggests 12 weeks of exercise therapy
• Injection: In the case of refractory symptoms, only one corticosteroid injection may be
considered at the discretion of the orthopaedic consultant

Referral on for • If no improvement after 12 weeks refer to orthopaedic surgeon

orthopaedic
PROGNOSIS:
opinion:
• Usually self-limiting
• Duration is between 6 months and 2 years
• 20 % of people still report symptoms after 1 year

DIAGNOSIS: OA OF THE ELBOW JOINT

TYPE OF
GUIDELINES
INFORMATION
Background Osteoarthritis of the elbow occurs when the cartilage surface of the elbow is damaged or
information becomes worn. This can happen because of previous injury such as dislocation or fracture, or
it may be the result of degenerative joint disease. OA usually affects the weight-bearing joints.
The elbow is one of the least affected joints due to the congruence of the joint surfaces and
the strong stabilising ligament complex. Elbow OA that occurs without previous I injury is more
common in men than women. Onset typically occurs in patients 50 years of age or older, but
some patients can have symptoms earlier.

Subjective • Most patients who are diagnosed with elbow OA have a history of injury to the elbow joint,
information possibly fracture or dislocation
• Risk of elbow OA increases if the patient needed surgery to repair the injury
• Injury to the ligaments of the elbow can also lead to OA due to increased forces across the
joint surfaces
• Work or sporting activities may exacerbate symptoms where the patient places more
demands on the joint than it can withstand
• Pain may experience around the joint and down into the forearm
• Patient may describe a loss of movement
• Patient may report a sensation of locking or grating
• May report joint swelling and stiffness after activity and rest
• In the later stages of elbow OA, patient may report numbness in the ring and little finger on
the affected side due to irritation/.compression of the ulnar nerve in the cubital tunnel

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DIAGNOSIS: OA OF THE ELBOW JOINT
TYPE OF
GUIDELINES
INFORMATION
Examination • Loss of normal range of movement- loss of extension is more common that a loss of flexion
findings • Catching or grating with movement
• Muscle weakness
• In severe cases may be some evidence of joint instability/ligament laxity
• Loss of sensation in the ulnar nerve distribution in the forearm/hand ( later stages)

Investigations AP and lateral elbow views

Conservative • Treatment depends on the stage of the disease, previous history, expectations of the patient,
management overall medical condition and results if diagnostic x-rays
• Early stages of elbow OA, most common treatment is non-surgical
• NSAIDs/analgesia- refer to GP
• Physiotherapy to improve /maintain AROM, muscle strength, restore/maintain function
• Refer to orthopaedic consultant if deepening on stage of disease and function

Referral on for • If x-ray shows arthritic changes with limitation of function, refer directly to Orthopaedic
orthopaedic Surgeon
opinion

DIAGNOSIS: LOOSE BODY

TYPE OF
GUIDELINES
INFORMATION
Background Rare condition, will few cases every year to be referred
information

Subjective • Pain at the elbow joint

History • Locking
• Grating or crepitus with movement
• Swelling

Examination Clicking and locking of the elbow, which may be painful

findings • Possible swelling
• May have block to full extension

Investigations • X-ray A-P and lateral elbow views

Conservative • Injection: NOT indicated

management

Referral on for • If loose body is evident on x-ray and patient has pain and locking refer on to Orthopaedic
orthopaedic Surgeon
opinion:

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DIAGNOSIS: NERVE ENTRAPMENT AT THE ELBOW
TYPE OF
GUIDELINES
INFORMATION
Background Cubital Tunnel Syndrome:
information
The ulnar nerve is one to the three main nerves in your arm. It travels from your neck down
into your hand. It can be restricted in several places in the arm, beneath the collar bone, at the
elbow and wrist. Most common place for compression of the nerve is behind the inside part of
the elbow. Ulnar nerve compression at the elbow is often called cubital tunnel syndrome. Some
factors may predisposes patients to the condition such as; prior fracture or dislocation, bony
spurs, OA elbow, cysts near the elbow and repetitive or prolonged activities that require the
elbow to be bent or flexed for prolonged periods.

Subjective • Numbness and tingling sensation in the hand and fingers (little, ring finger most affected)
History • Pain at the elbow and into lateral border of the forearm
• Weakness of grip (usually associated with more severe cases)
• Symptoms made worse with repeated or sustained elbow flexion
• Waking at night with numb fingers
• May reported intermittent swelling

Examination • Reduced grip

findings • Muscles wasting in the hand (more severe cases)
• Positive tinnels sign at the elbow/guyons canal
• Reproduction of symptoms with sustained elbow flexion
• Altered movement of the ulnar nerve at the elbow during flexion/extension
• Claw-like deformity of the hand (more severe cases)
Investigations • X-ray may be useful to eliminate possible cause of symptoms such as OA, bony spurs, loose
bodies
• Consider Nerve Conduction Studies Referral prior to referral to secondary

Conservative • Physiotherapy 6-12 weeks

management • Consider analgesia and NSAIDs injection
Splinting

Referral on for • Referral to orthopaedic surgeon if abnormal nerve conduction studies and if no improvement
orthopaedic with physiotherapy in 6-12 weeks
opinion: • If subluxing ulna nerve or severe intrinsic wasting please refer to orthopaedic surgeon
Prognosis following surgery:
• Results of surgery are generally good
• 85% of patients respond to some form of surgery
• Each method of surgery has a similar success rate for routine case of nerve compression
• If the nerve is has been compressed for some time or if muscle wasting is evident, the nerve
may not be able to return to normal
• Some symptoms may remain after surgery
• Nerves recover slowly, it may take a long time to assess the response to surgery

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DIAGNOSIS: UNSTABLE ELBOW
TYPE OF
GUIDELINES
INFORMATION
Background Elbow instability is a looseness in the elbow joint that may cause the joint to catch, pop, or slide
information out of place during certain arm movements. It most often occurs as a result of an injury typically
an elbow dislocation. This type of injury can damage the bone and ligaments that surround
the elbow joint. There are 3 different types of recurrent/chronic elbow instability: Posterolateral
rotatory, valgus and varus posteromedial rotatory instability.
• Posterolateral rotatory instability - elbow slides in and out of the joint due to an injury of
the lateral collateral ligament complex. Most common type of recurrent instability. Typically
caused by trauma such as a fall on an outstretched hand, may develop as a result of a
previous surgery or longstanding elbow deformity
• Valgus instability - Unstable due to an injury of the ulnar collateral ligament. Most often
caused by repetitive stress as seen in overhead athletes. May also result from a traumatic
event
• Varus posteromedial rotatory instability - Elbow slides in and out of the joint due to a
injury of the lateral collateral ligament complex, in addition to a fracture of the coronoid
portion of the ulna bone. Typically caused by a traumatic event such as a fall

Subjective • History of previous elbow dislocation or previous surgery may be described/reported

History • Patient feels as though elbow is giving way or ‘pop’ out of place
• Unable to do press ups or push up off chair
• May describe locking, catching or clicking at the elbow
• May feel pain on the inside of elbow with overhead activity or throwing an object at speed

Examination • Varus +/- valgus stress tests may be positive

findings • Tenderness on palpation
• Muscle weakness

Investigations • X-ray elbow AP and lateral ( although x-rays cannot show soft tissue, they can be helpful in
identifying fractures, dislocations or subtle changes in alignment of the elbow)
• MRI - may show tears in the ligaments, muscles, tendons (not typically necessary for a
diagnosis of elbow instability, request should be left to the discretion of orthopaedic
consultant

Conservative • If mild signs or symptoms: refer to Physiotherapy

management • Activity modification
• NSAIDs

Referral on for • Elbow instability is a rare problem

orthopaedic • But it is complex and needs specialist surgery if symptoms do not improve with conservative
opinion: management
• A highly competitive athlete who has a complete tearing of the ulnar collateral ligament may
require surgery to return to normal function
• If obviously unstable: Referral to Orthopaedic Surgeon

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MSK SERVICES PATHWAY - HAND PATHOLOGY
GPs to follow guidance offered within this pathway and where relevant refer using
Ardens templates and within remit of CCG Restricted and Not Routinely funded policy.

RED FLAG

• History of or suspected malignancy from

Diagnosis to Clinical Examination
monitor • Active infection
• Cervical stenosis

Medical Professionals seeing patients with

History & MSK complaints in primary care should be
Symptoms trained in assessing for alarming features and
red flags in all patients.

ASSESSMENT & DIAGNOSIS OF OTHER CONDITIONS

Dupuytren’s contracture

Hand/wrist OA

Carpal tunnel syndrome

Cubital tunnel

Tendinopathies

Distal RU joint / TFCC injuries

Ganglions or finger cysts

Trigger fingers

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RED FLAG SCREENING: SPECIFIC FOR HAND PATHOLOGY
Red Flag Consider Urgent Referral if:
diagnoses
• History of or suspected possible malignancy from clinical examination.
• Features suggesting cervical stenosis, e.g. central cord symptoms/signs.
Consider referral to ED/fracture clinic:
• Active infection.

Injuries Acute bone, joint or tendon injuries should be directed to ED/fracture clinic.
Sequelae/complications of previous injury should be referred onwards to secondary care with an
urgency directed by clinical interpretation.

DIAGNOSIS: DUPUYTREN’S CONTRACTURE

TYPE OF
GUIDELINES
INFORMATION
Background Consider the Procedures of Limited Clinical Value (PLCV) and Procedures Not Funded (PNF)
information Policy – Palmar Fasciectomy, Collagenase injections and radiation therapy to treat Dupuytren’s
contracture are restricted procedures.
Dupuytren’s contracture is a progressive fibroproliferative disease that is believed to show
autosomal dominant inheritance. It affects between 3–5% of the population and is up to 6 times
more common in men than women.

Subjective Known risk factors:

History
• Family history and/or previous medical history diabetes.
• Occasionally due to liver disease
• Epilepsy (unclear if link to epilepsy itself or anti-convulsant medication)
• Greater weekly alcohol intake
• Hand trauma (link is unproven)
Patients describe difficulties with face washing, combing their hair, and putting their hands in
their pockets or fitting them into gloves.

Examination Natural progression of Dupuytren’s:

findings
• Skin thickening and pitting
• Nodule formation
• Cord formation
• Contractures
Look for Garrod’s knuckle pads (dorsal fibromatosis of the PIP joints) and nodules on the soles
of feet (Ledderhose’s), which indicates more aggressive disease.
The Hueston table-top test involves the patient attempting to lay the palm of the hand flat on a
table surface. The test is positive if the patient is unable to flatten the hand on the table.

Investigations Investigations are not indicated

Conservative For people with Dupuytren’s disease who do not have contracture or any significant loss
management of function:
• No treatment is necessary at this stage.
• Provide an explanation of the condition and reassure the person that any painful nodules
should improve with time.
• Advise the person to return for review if a contracture develops, as referral is then
recommended.
Consider referral to Hand Therapy to maximise function and ADL

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DIAGNOSIS: DUPUYTREN’S CONTRACTURE
TYPE OF
GUIDELINES
INFORMATION
Referral on for Consider referral if:
secondary care • Any contracture at PIP joint or significant contracture at MCP joint, in line with PLCV policy
opinion: which states:
• MCP contracture >30 degrees
• Any PIP contracture
• 1st web contracture
• Significant limitation of hand function in activities of daily living.
• Radial sided disease.

DIAGNOSIS: HAND/WRIST OA
TYPE OF
GUIDELINES
INFORMATION
Background Osteoarthritis is defined as a disorder of synovial joints which occurs when damage triggers
information repair processes leading to structural changes within a joint.
Joint damage may occur through repeated excessive loading and stress of a joint over time,
or by injury. These repair processes alter the structure of the joint over time, causing typical
features of:
• Localized loss of cartilage.
• Remodelling of adjacent bone and the formation of osteophytes (new bone at joint margins).
• Mild synovitis (inflammation of the synovial membrane that lines the joint capsule).
In some people, these repair processes may alleviate symptoms, but in others they cannot fully
compensate for the joint damage, and symptoms of pain and stiffness may occur.
Any synovial joint can be involved, and the most commonly affected peripheral joints are the
knees, then the hips, and the small joints of the hand.

Subjective Typically, there is a history of:

History
• activity-related joint pain — typically only one or a few joints are affected at any one time, and
pain develops over months or years;
• no morning joint-related stiffness, or morning stiffness lasting no longer than 30 minutes; and
• functional impairment.
If multiple joints involved consider inflammatory arthropathy (especially if DIPs spared).

Examination Osteoarthritis of the hand typically affects the first CMC joint at the base of the thumb, the
findings distal interphalangeal (DIP) joint, and the proximal interphalangeal (PIP) joint.
• Pain can radiate distally towards the thumb or proximally to the wrist and distal forearm, and
is often exacerbated by pinching actions or strong grip.
• There may be wasting of the thenar muscles at the base of the thumb.
• The CMC joint may develop a fixed flexion deformity, with hyperextension of the distal joints.
• In advanced disease, there may be ‘squaring’ at the joint caused by subluxation (partial
dislocation), formation of osteophytes, and remodelling of the bones.
• Initially, there may be features of inflammation such as pain, warmth, redness, and swelling of
affected DIP and PIP joints.
• As disease progresses, there may be ulnar or radial deviation at affected joints.
May have associated features including:
o Mucoid cysts (painful mucus-filled cysts) adjacent to the joint on the dorsum of the finger,
which may cause longitudinal ridging of the nail.
o Heberden’s and Bouchard’s nodes (bony nodules on the dorsum of the finger next to the
DIP and PIP joints, respectively).

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DIAGNOSIS: HAND/WRIST OA
TYPE OF
GUIDELINES
INFORMATION
Investigations Routine X-ray of the affected joint(s) is not usually needed to confirm the diagnosis.
Consider arranging an X-ray:
• if there is diagnostic uncertainty;
• to exclude alternative conditions;
• if there is a sudden clinical deterioration in symptoms.
Note: structural changes on X-ray may not correlate with reported symptoms and functional
impairment.

Conservative • Advise on nature of OA involvement/natural evolution of OA and treatment options

management • Consider analgesia or NSAIDs – if ineffective consider topical capsaicin
• Splinting specific to affected joint (wrist, thumb, finger) and advice on activity modification
(ergonomic advice)
• 1st dorsal interosseous strengthening for base of thumb OA
• Corticosteroid injections
Consider referral to Hand Therapy

Referral on for Referral to specialist hand surgeon for review and further management if:
secondary care
• no improvement after 3 months of conservative management; or
opinion
• insufficient improvement with previous appropriate conservative management.

DIAGNOSIS: CARPAL TUNNEL SYNDROME

TYPE OF
GUIDELINES
INFORMATION
Background Consider PLCV and PNF Policy – carpal tunnel release is a restricted procedure.
information
Carpal tunnel syndrome is a collection of symptoms and signs caused by compression of the
median nerve in the carpal tunnel at the wrist.
• The carpal tunnel is an anatomical compartment bounded on three sides by carpal bones
and on the palmar side by the transverse carpal ligament. It contains the median nerve and
the flexor tendons.
• Reduction in the dimensions of the carpal tunnel or increase in the volume of its contents
produce an intermittent or sustained high pressure in the tunnel which causes ischaemia of
the median nerve and impairs nerve conduction leading to paraesthesia, pain and decreased
function of the nerve.
• If pressure on the nerve is continued this can lead to segmental demyelination with more
constant and severe symptoms which are in some cases associated with muscle weakness
and wasting.

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DIAGNOSIS: CARPAL TUNNEL SYNDROME
TYPE OF
GUIDELINES
INFORMATION
Subjective Potential risk factors, include
History
• variations in the anatomy of the carpal tunnel,
• age over 30 years,
• high BMI,
• pregnancy,
• occupations involving repetitive movements of the wrist
• CTS is three times more common in women than men
Other risk factors include
• Peri-menopause
• Osteoarthritis and rheumatoid arthritis
• Psychosocial factors such as low mood
• Distal upper limb tendinopathies and tendonitis
• Vibration
• Hypothyroidism
• Diabetes mellitus
• Acromegaly
• Space occupying lesions including osteophytes and ganglion cysts.
• Wrist trauma
Cause is likely to be multifactorial.
Typical symptoms include
• intermittent tingling, numbness or altered sensation and burning or
• pain in the distribution of the median nerve (the thumb, index finger, middle finger, and radial
half of the ring finger).
• symptoms are often worse at night and can disrupt sleep.
• may affect one or both hands.
• pain in the hand may radiate up the arm into the wrist or as far as the shoulder.
• loss of grip strength, clumsiness and reduced manual dexterity

Examination Look for:

findings
• Sensory loss in the distribution of the median nerve.
• Atrophy of the muscles of the thenar eminence.
• Reduced strength of thumb abduction.
• Dry skin on the thumb, index, and middle fingers – trophic ulcers at the tips of the digits may
• be present.
• Positive findings on tests such as Phalen’s, Tinel’s and carpal tunnel compression (Durkan’s)
test
Exclude nerve root involvement from cervical spine by history and clinical examination.

Investigations DO NOT REFER FOR IMAGING

Nerve Conduction Studies (EMG) to be considered if: doubt over diagnosis, possible dual
pathology (double crush, diabetic neuropathy etc), recurrence after previous surgery.
Arrange appropriate investigations (such as blood tests or ultrasound scan) if a specific
underlying cause (such as hypothyroidism or ganglion cyst) is suspected

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DIAGNOSIS: CARPAL TUNNEL SYNDROME
TYPE OF
GUIDELINES
INFORMATION
Conservative In the first instance CTS can be managed by:
management
• optimising treatment of any underlying condition, such as osteoarthritis, rheumatoid arthritis
or hypothyroidism;
• advising the person that lifestyle modification / work adaptations may help; and
• splinting in a neutral position – this can help with night time symptoms in particular.
DO NOT PRESCRIBE NSAIDS OR DIURETICS TO TREAT CTS.
Consider up to two corticosteroid injections if adequately trained in case of :
• no neurological deficit; and-
• no improvement from night splint; or
• negative NCS but good history

Referral on for In line with PLCV policy. Consider referral if:

secondary care
• partially or unresponsive to conservative management or unconfirmed diagnosis, refer for
opinion
surgical opinion
• severe symptoms affecting function or neurological deficit (continuous decreased sensation
+/- muscle atrophy)

DIAGNOSIS: CUBITAL TUNNEL

TYPE OF
GUIDELINES
INFORMATION
Background Compression of the ulnar nerve at the elbow.
information

Subjective Typical symptoms described are:

History
• paraesthesia/numbness in ulnar nerve distribution;
• waking at night; and
• decreased intrinsic muscle strength +/- wasting.

Examination Typical features are:

findings
• Decreased sensation in ulnar nerve distribution.
• Intrinsic muscle weakness/wasting.
• Early fatigue of 1st dorsal interosseous muscle.
• Wartenberg’s sign (direct tenderness, sensory changes, and positive Tinel’s sign over the
radial sensory nerve)
• Ulnar clawing.
Exclude nerve root involvement from cervical spine by history and clinical examination.

Investigations Consider elbow x-ray if history of OA, or previous trauma to, elbow.
Consider nerve condition studes to confirm diagnosis.

Conservative Postural advice.

management

Referral on for Refer to upper limb/hand surgeon if:

secondary care
• significantly troublesome symptoms, sleep disturbance;
opinion
• any wasting/weakness; and
• patient willing to consider surgery.

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DIAGNOSIS: TENDINOPATHIES
TYPE OF
GUIDELINES
INFORMATION
Background The basic aetiology is a stenosing tenosynovitis as the tendon passes through its retinacular
information sheath. Repetitive shear stress through the sheath causes irritation to the tendon and its
synovial lining (tenosynovium) with inflammation and hypertrophy, along with fibrosis of the
retinacular sheath. Over time, the canal will narrow to a point that precludes smooth gliding of
the tendon: stenosing tenosynivitis
The most common is De Quervain’s: tendonitis of the abductor pollicis longus and extensor
pollicis brevis tendons as they pass through the first dorsal compartment of the wrist at the
radial styloid process.

Subjective Exclude acute injury/tendinopathy secondary to recent injury

history
De Quervain’s presents with pain, tenderness, and swelling localised to the radial side of the
wrist 1 to 2 cm proximal to the radial styloid. It is aggravated by thumb movement.
Risk factors include:
• age (40-60)
• female
• hx of current concomitant conditions with similar pathology
• insulin-dependent diabetes
• pregnancy and lactation

Examination For De Quervain’s pain is exacerbated by ulnar deviation of the wrist when the thumb is
findings clasped in the palm (Finkelstein test).
Rule out CMC arthritis (direct tenderness over the joint and positive grind test) and radial
sensory nerve neuritis (Wartenberg’s syndrome
presenting with direct tenderness, sensory changes, and positive Tinel’s sign over the radial
sensory nerve)

Investigations Consider x-ray wrist of base of thumb to exclude other diagnosis and evaluate underlying OA as
main cause of tendinopathy

Conservative Most primary stenosing tendinopathies in adults can be successfully treated non-
management surgically with:
• advice on relative rest education with modification of hand/wrist activities
• analgesia/NSAIDs if suitable.
• splinting relevant to type of tendinopathy
Consider corticosteroid injection in case of Dequervain’s tendinopathy can only be considered
if no improvement after 4 weeks of conservative management and healthcare professional
adequately trained
Consider referral to Hand Therapy

Referral on for If symptoms recur after an injection and modification of activities refer to specialist hand
secondary care surgeon.
opinion

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DIAGNOSIS: DISTAL RU / TFCC INJURIES
TYPE OF
GUIDELINES
INFORMATION
Background The Triangular Fibrocartilage Complex (TFCC) is the ligamentous and cartilaginous structures
information that separate the radiocarpal from the distal radioulnar joint. The TFCC consists of an articular
disc, meniscus homologue, ulnocarpal ligament, dosal & volar radioulnar ligament and extensor
carpi ulnaris sheath.

Subjective Mechanism of Injury:

history
• Occurs with compressive load on TFCC during marked ulnar deviation
• Forced ulnar deviance (i.e. swinging bat, racket, etc) causes increased load on TFCC

Examination Provocative tests:

findings
• Tenderness on Palpation: The TFCC is located between the os pisiform, the ulnar styloid and
the FCU.
• TFCC Compression Test: Pain/clicking with a combination of ulnar deviation and axial
compression while performing repetitive flexion and extension.

Investigations Normal x-ray

Only refer for further imaging (MR arthrogram) if change of management being considered

Conservative Most TFCC injuries can be managed conservatively through:

management
• RICE and activity modification in acute phase; followed by
• wrist mobilization / ROM exercises; followed by
• intensive wrist strengthening

Referral on for Refer for orthopaedic opinion only if change of management being considered
secondary care
opinion

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DIAGNOSIS: WRIST OR FINGER GANGLION/CYSTS
TYPE OF
GUIDELINES
INFORMATION
Background Consider PLCV and PNF Policy – excision of ganglion on wrist is a restricted procedure
information

Subjective Risk factors:

history
• female;
• age 10 to 30 years;
• trauma - a definitive link between traumatic injuries of the wrist joint and ganglion formation
has not yet been confirmed;
• scapholunate instability.
Exclude other possible causes of swelling by history and clinical examination.

Examination Typical features on examination:

findings
• subcutaneous wrist mass
• Diameter is typically 1 to 4 cm, although can reach up to 8 cm.
• Characteristics include being smooth and slightly mobile with no connections to underlying
tendons.
• wrist pain
• Patients may experience occasional aching discomfort secondary to compression of
surrounding structures.
• non-tender mass
• There is usually minimal to no pain on palpation unless the cyst is overlying neurological
structures.
• increased mass size after activity
• Ganglions can often increase temporarily with strenuous activity of the involved extremity.
• trans-illuminating mass
• Typical ‘glow’ of a fluid-filled cyst is observed when a penlight is held next to the cyst.

Investigations X-ray hand/wrist to exclude underlying significant OA/ligamentous injury

Conservative Educate patient with regard to nature, history of ganglion secondary to OA. They are almost
management always self-limiting. Most disappear within 5 years.
Injections are not indicated. Aspiration under local anaesthetic by orthopaedic surgeon can be
considered if sizeable ganglion, interfering with daily activities.

Referral on for Consider referral only if:

secondary care
• significant underlying joint involvement or pain;
opinion
• not well managed by conservative means; or
• if unsure of diagnosis.

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DIAGNOSIS: TRIGGER FINGER
TYPE OF
GUIDELINES
INFORMATION
Background Consider PLCV and PNF Policy – trigger finger release is a restricted procedure
information The basic common features of all stenosing tendinopathies are pain, swelling, and tenderness
at the point where an extrinsic tendon enters its retinacular sheath. Symptoms increase with
active motion and more so with resisted motion. Lack of motion associated with increased pain
may signify locking, and patient may report needing forcibly straighten fingers when locked.

Subjective Risk factors – as for De Quervain’s

history
Consider combined CTS involvement through history and clinical diagnosis.

Examination Digital flexor tendon tendonitis at the A1 pulley in the hand (trigger finger) typically presents
findings with painful catching or popping of the flexor tendon, which occurs as the patient flexes and
extends the digit. The digit may be locked in flexion; passive manipulation into extension may
release the locking. Prolonged neglect will result in flexion contracture of the finger. A tender
nodule may be palpable at the A1 pulley.
Trigger finger classification
• Grade 0: mild crepitus in the non-triggering finger.
• Grade 1: no triggering, but uneven finger movements.
• Grade 2: triggering is actively correctable.
• Grade 3: usually correctable by the other hand.
• Grade 4: the digit is locked.

Investigations Not indicated

Conservative Education of patients with regard to diagnosis.

management Corticosteroid injection at A1 pulley if troublesome/locked.

Referral on for If locked (irreducible) and does not release 1-2 weeks after injection, or if no improvement /
secondary care recurrence after 1 injection, consider referral to hand surgeon.
opinion

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MSK SERVICES PATHWAY - LOW BACK PAIN PATHOLOGY
FOR PATIENTS AGED OVER 16 YEARS

GPs to follow guidance offered within this pathway and where relevant refer using
Ardens templates and within remit of CCG Restricted and Not Routinely funded policy.

RED FLAG

• Spinal malignancy • Abdominal Aortic Aneurysm

• Metastatic Spinal CordCompression • Visceral Referral
Diagnosis to • Fracture • Lumbar Radiculopathy with
monitor • Cauda Equina muscle power of < 3/5, such
• Inflammatory Back Pain as drop foot.
• Infection

Medical Professionals seeing patients with

History & MSK complaints in primary care should be
Symptoms trained in assessing for alarming features and
red flags in all patients.

Injury Consider admission/urgent referral

ASSESSMENT & DIAGNOSIS OF OTHER CONDITIONS

Tool to aid clinical judgement when serious spinal pathology suspected

Mechanical non-specific low back pain

Mechanical low back pain with no leg symptoms overview

Low back and leg pain/Lumbar radiculopathy

Lumbar radicular pathway overview

Coccygeal pain

Other specific causes of low back pain

When to order imaging

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RED FLAG SCREENING: SPECIFIC FOR LOW BACK PATHOLOGY
Red Flags/ Medical Professionals seeing patients with MSK complaints in primary care should be trained in
conditions assessing for alarming features and red flags in all patients.
that will alter
• Spinal malignancy
management
• Metastatic Spinal Cord Compression
immediately
• Fracture
• Cauda Equina
• Inflammatory Back Pain
• Infection
• Abdominal Aortic Aneurysm
• Visceral Referral
• Lumbar Radiculopathy with muscle power of < 3/5, such as drop foot.

History & • Cauda equina syndrome1.

Symptoms
o Severe or progressive bilateral neurological deficit of the legs, such as major motor
weakness with knee extension, ankle eversion, or foot dorsiflexion.
o Recent-onset urinary retention (caused by bladder distension because the sensation of
fullness is lost) and/or urinary incontinence (caused by loss of sensation when passing urine).
o Recent-onset faecal incontinence (due to loss of sensation of rectal fullness).
o Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia).
o Unexpected laxity of the anal sphincter.
• Referral should be made to local A and E department immediately by assessing
clinician (GP, ANP, APP, Physiotherapist)
• For MSK APP triage staff and MSK Core physiotherapy staff, patient letter is available
on SystmOne to be completed and given to patient to attend A and E
• Spinal fracture1.
o Sudden onset of severe central spinal pain, which is relieved by lying down.
o A history of major trauma (such as a road traffic collision or fall from a height), minor
trauma, or even just strenuous lifting in people with osteoporosis or those who use
corticosteroids.
o Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra)
may be present.
o There may be point tenderness over a vertebral body.
• Referral should be made to local A and E department immediately by assessing
clinician (GP, ANP, APP, Physiotherapist)
• Spinal Malignancy11.
o Age <20 or > 50 is higher risk group.
o Gradual onset of symptoms.
o Severe unremitting pain that remains when the person is supine, aching night pain
that prevents or disturbs sleep, pain aggravated by straining (for example, at stool, or when
coughing or sneezing), and thoracic pain.
o Localised spinal tenderness.
o No symptomatic improvement after four to six weeks of conservative low back pain therapy.
o Unexplained weight loss, fever, malaise.
o Past history of cancer - breast, lung, gastrointestinal, prostate, renal, and thyroid cancers
are more likely to metastasize to the spine.
• Referral should be made to local A and E department immediately by assessing
clinician (GP, ANP, APP, Physiotherapist) if fractures are noted on any form of
radiological investigation
• Urgent referral should be made to local spinal unit
• Infection/Inflammatory back pain (such as Ankylosing Spondylitis, discitis, vertebral
osteomyelitis, or spinal epidural abscess)1.

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RED FLAG SCREENING: SPECIFIC FOR LOW BACK PATHOLOGY
History & o Atypical Presentation such as prolonged EMS, presence of constitutional symptoms.
Symptoms o Suspect shingles (herpes zoster) if the person has unilateral pain and rash in the
distribution of a dermatome.
o Could be multiple systems affected – for AS, pt may also have received treatment for
conditions such as enthesitis, uveitis, cardiovascular problems.
o Fever
o Tuberculosis , or recent urinary tract infection.
o Diabetes.
o FH of Tuberculosis.
o History of intravenous drug use.
o HIV infection, use of immunosuppressants, or the person is otherwise immunocomprimised.
o Systemic (constitutional) symptoms, e.g. fever, chills, unexplained weight loss, referral.
• Referral should be made to rheumatology specialist in secondary care by assessing
clinician (GP, ANP, APP, Physiotherapist)
Fracture1
• Three main categories - traumatic, insufficiency and pathologic.
• Risk Factors: Osteoporosis, Trauma (RTC, fall, assault), prolonged use of steroids, Paget’s
Disease, female, overuse/overtraining, lumbopelvic radiation, osteomyelitis, multiple myeloma,
• Referral should be made to local A and E department immediately by assessing
clinician (GP, ANP, APP, Physiotherapist) for acute management.
• Urgent referral to spinal unit
• Referral to 2 week wait if appropriate
Metastatic Spinal Cord Compression (MSCC)1
• Spinal cord compression by direct pressure and/or induction of vertebral collapse or instability
by metastatic spread or direct extension of malignancy that threatens or causes neurological
disability.
• Incidence – 80 cases per million people every year2.
• Constitutional symptoms – Unexplained weight loss, Non-mechanical night pain, fever,
malaise.
• Other Symptoms – additional pain in the cervical spine or thoracic spine, significant
change in the nature of pain, spinal pain aggravated by straining (toilet, coughing, sneezing),
localised spine tenderness, neurological symptoms (radicular pain, any limb weakness,
difficulty in walking, sensory loss, loss of coordination, Bladder and Bowel dysfunction, saddle
anaesthesia).
• Referral should be made to local A and E department immediately by assessing
clinician (GP, ANP, APP, Physiotherapist) to address acute symptoms
• Urgent referral to spinal unit
AAA3
• 65-75% of AAA cases are asymptomatic .
• Most common symptoms is awareness of pulsating mass in abdomen, with or without pain,
following by abdominal pain and back pain (varying from deep and dull pain to knifelike pain
and the patient may complain of increased shortness of breath; symptoms may be
aggravated by general exertion but can appear mechanical in nature.
• Groin, buttock or flank pain may be experienced because of increased pressure on other
structures and pain may also radiate to the neck, shoulders, chest or posterior thighs.
• Risk Factors: Age > 60, Males (6 male: 1 female for incidence), cardiovascular risk factors,
family history of AAA and infectious/inflammatory disorders.
• Abdominal Aortic palpation – Pulsating Mass may be present; Presence of >3cm diameter on
aorta palpation is regarded as AAA N.B - ability to palpate is influenced by abdominal girth
and diameter of aneurysm.
• Referral should be made to local A and E department immediately by assessing
clinician (GP, ANP, APP, Physiotherapist)

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 RED FLAG SCREENING: SPECIFIC FOR LOW BACK PATHOLOGY
History & Visceral Referral4
Symptoms
• Accounts for 2% of LBP (including AAA).
• Possible visceral referrals include: bladder, kidney (flank pain), ureter, liver (right-sided
thoracolumbar pain).
• If visceral referral possible cause and assessed by MSK Triage team or core
physiotherapy team. Refer back to GP with letter.

References
1
NICE endorsed low back pain pathway (2017) X-ray within primary/
2
NICE 2008 MSCC guidelines intermediate care if no red
3
Knaap and Powell (2011) flags and pain controlled.
4
Goodman and Synder (2012)
Secondary Care - if red flags
or pain not controlled.
TOOL TO AID CLINICAL JUDGEMENT WHEN SERIOUS PATHOLOGY SUSPECTED

SUBJECTIVE FURTHER EXAMINATION Suspected vertebral

Fracture
EXAMINATION • Recent/Sudden onset of
deformity that is not * can be due to neoplasm,
FINDINGS passively correctable osteoporosis, hemangioma If high index suspicion
or trauma Urgent referral for oncology
HISTORY emergency (per local
• Sudden vs Gradual pathway)

RADIATION to leg?
SPINAL TENDERNESS &
MECHANISM OF RED FLAGS
• Inpatient with known Suspected Metastatic Cord
INJURY High trauma or Compression
prior cancer
Penetrative trauma? Medical Emergency
• If after violent trauma
Insiduous? • Abnormal neurology
Cauda Equina Syndrome Urgent referral into A&E with
• Positive UMN testing accompanying letter from
NEUROLOGY? ?Unstable spinal injury, clinician
• Loss of anal tone or
visceral injury or spinal
peritineal sensation
RED FLAGS/ cord injury
CONSTITUTIONAL
SYMPTOMS?

PAST MEDICAL AAA - suspected rupture/

AAA EXAMINATION high risk rupture
HISTORY AND
• History increases suspicion (Emergency)
TREATMENT - VIEW
• Pulsating Mass may be • Patient transported to A&E
COMPLIANCE/ present on observation AAA or Ruptured AAA
immediately. Clinician to
RESPONSE • Presence of >3cm diameter suspected
phone A&E to notify them/
on aorta palpation is send letter once patient
ALTERED SENSATION regarded as AAA has left.
OR LOSS OF MOTOR • NB - ability to palpate is
Suspected AAA - not
CONTROL OF influenced by abdominal
deemed high risk
girth and diameter of
BOWEL/BLADDER? aneurysm - do not go by • Letter to GP - Patient to see
objective examination GP within 48 hours. GP to
PRIOR CANCER findings alone refer for AAA screening.
HISTORY?
(Particularly those that
metastasise to bone)

FAMILY HISTORY NEUROLOGICAL

EXAMINATION Lumbar Radiculopathy
Motor Power <3/5
RISK FACTORS Motor Power <3/5 at 1
neurological level and no Lumbar Radiculopathy Refer to MSK triage Hub for
AGE/DEMOGRAPHIC serious abnormal neurology Motor Power < 3/5e.g. triage - NUH Surgical Clinic
such as +ve UMN testing Drop Foot categorise as ‘urgent for
spinal opinion’.

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DIAGNOSIS: MECHANICAL NON-SPECIFIC LOW BACK PAIN (ACUTE, SUBACUTE, PERSISTENT)
TYPE OF
GUIDELINES
INFORMATION
Background • LBP is the largest single cause of loss of disability adjusted life years and the largest single
information cause of years lived with disability in England.3
• It affects around one third of the adult population each month.2
• In most people, low back pain is non-specific and serious/specific causes are rare.
• Patient-centred approach is best with a focus on self-management.
• Appropriate acute back pain management has the potential to reduce the disabling effects of
spinal pain with improvements on physical, emotional and social function.
• Most episodes of non-specific back pain resolve within four weeks with self-care.
• People with low back pain who are at higher risk of long-term pain and functional disability
include those with:
o Pain lasting for longer than 12 weeks.
o Psychosocial distress.
o Maladaptive coping strategies such as avoidance of work, movement, or other activities
due to fear of exacerbating back pain.
o Pain coping characterised by excessively negative thoughts about the future
(‘catastrophising’).
• People who have had low back pain often have episodes of recurrence and may develop
repeated ‘acute on chronic’ symptoms.
• It is estimated that between 5 and 30% of patients who develop acute and subacute LBP go
on to develop persistent low back pain2.

Subjective • Tension, soreness or stiffness in the lumbosacral region which varies with changes in posture
History and/or movement.2
• History questioning should include an assessment for the presence of red flag symptoms,
which would imply serious conditions.
• If signs of serious conditions (red flags) present, specialist referral should be made.
• The assessment should also capture potential biopsychosocial barriers to an improvement in
the patient’s condition so that subsequent treatment can be tailored to address these barriers.
Examples of potential barriers include high levels of pain, perceived frailty or vulnerability,
psychosocial factors and maladaptive strategies such as kinesophobia or prolonged bed rest.
• The assessing clinician could also use the StArt back pain tool to as part of the assessment
for the person’s risk of back pain disability and this can then guide decisions regarding
management2.
• Subjective Markers could include:
• The level of function such as walking distance, whether the patient is at work.
• VAS score/duration of pain/duration of time it takes to relieve symptoms.
• Completion of STarT back tool
At follow-up, if symptoms persist or are worsening the clinician should continually
reassess for red flags and any barriers to the patient’s improvement (for example,
maladaptive strategies and negative perception of condition).

Physical • Examination for features of mechanical back pain, for example pain is reproduced by back
Examination movement and/or changes in postures.
findings • Remaining examination led by patient history (for example functional demonstration of
the movement/position identified by the patient to provoke their symptoms, neurological
assessment).
• Assess for spinal deformity (scoliosis, kyphosis or otherwise).
• Neurological assessment if appropriate
• Screen hip and sacro-iliac joint

Investigations • Do not offer imaging (x-ray, MRI) for patients with suspected mechanical non-specific low
back pain in the absence of leg pain and or red flags
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DIAGNOSIS: MECHANICAL NON-SPECIFIC LOW BACK PAIN (ACUTE, SUBACUTE, PERSISTENT)
TYPE OF
GUIDELINES
INFORMATION
Conservative Treatment should facilitate excellent patient compliance with high-quality conservative
management management strategies; these could include:
All clinical consultations should include reassurance/education to facilitate self-efficacy: -
• Use of different media (oral and written) to aid the person’s learning style. This includes the
MSK together self-help website.
• Use functional explanations for pain (sprained back, non-serious back pain). Example: “Many
people have back pain from time to time but it is rare for this to be caused by a specific
problem. Mostly all that is needed is to get your back moving again and things will settle down”.
• Avoid use of terminology/messages that may harm or hinder patients such as “wear and tear,
degeneration, crumbling”, “pain means harm”, “you should avoid bending/lifting.2
• Use terminology that can help promote resilience and facilitate improvements in people with
low back pain, example: “your back is one of the strongest structures in your body” and
encourage normal movement and activity.
• Address patient concerns about imaging where applicable.
• Promote good quality self-management.
• Facilitate early return to work – For example, use of fit notes to support return to work and
communicate suggestions to the employer. Help the person negotiate an early return to work if
at all possible. Consider the return to work scheme if the patient would like additional support
with this.
• Goal setting (SHORT/MEDIUM/LONG). Give realistic time scales.
• Shared decision-making.
Pain medication as required -
• Consider oral NSAIDs +/- gastroprotective medication if appropriate.1
• Weak opioids (with or without paracetamol) for managing acute low back pain only if an NSAID
is contraindicated, not tolerated or has been ineffective.1
Physiotherapy - Exercise (+/- manual therapy)
• Take the patient’s specific needs and preferences into account when choosing the type of
exercise and whether it is in a group or individual setting.
• Encourage activity and address inactivity; bed rest is not recommended.1
• Graded Exposure. Try to address psychosocial barriers such as fear-avoidance of activity/
unhelpful beliefs
• MSK Physiotherapists and APP triage team can refer into Bfit groups held across the hub sites
(Newark, Ashfield and Kings Mill)
In complex cases or where symptoms have not improved with 12 to 16 weeks of core
therapy: -
• Consider arranging band 7/8 MSK assessments and expertise via referral into the MSK alliance.
• Consider whether a (further) trial of 1:1 physiotherapy is indicated and/or other treatment
interventions from the MDT.
• Consider referral into PICs pain management services if all appropriate physiotherapy and
analgesic/exercise advice has failed to improve symptoms
Do not use or refer for these interventions1:
• Interferential therapy, PENS or TENS, ultrasound, acupuncture, or traction
• Belts, corsets, foot orthotics, or rocker sole shoes.
• Spinal injections for managing low back pain (except for considering radiofrequency
denervation for facet joint-related low back pain)

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 DIAGNOSIS: MECHANICAL NON-SPECIFIC LOW BACK PAIN (ACUTE, SUBACUTE, PERSISTENT)
TYPE OF
GUIDELINES
INFORMATION
Referral on for • Spinal surgery is no longer available for non-specific Low Back Pain (see Nice Guidance 59) - if
secondary care pain persists despite treatment, consider referral to local pain clinic. The spinal unit will no longer
opinion: accept these referrals.
Pain Management referral to PICs may be necessary:
• When there is diagnostic uncertainty
• Speciality as directed by clinical guidelines if alternative diagnosis is suspected
• If symptoms are not improving with 12-16 weeks of patient compliance with high-quality
conservative management (including physiotherapy input) and if the patient has seen band
7/8 clinicians, consideration can be made by the band 7/8 clinician to refer the patient on for
secondary care orthopaedic assessment to evaluate alternate diagnoses, consider investigative
measures and direct treatment.
FACET JOINT PAIN - Regarding facet joint pain - when to refer to secondary care pain
management services:-
- The features subjectively include: Increased pain unilaterally or bilaterally on lumbar
paraspinal palpation ▪ Increased back pain on 1 or more of the following: extension (more
than flexion) • rotation, extension/side flexion, extension/rotation • No radicular symptoms •
No sacroiliac joint pain elicited using a provocation test.5
- The patient has trialled good-quality conservative management (as described above) before
referring for consideration of radiofrequency denervation.
- For assessment for radiofrequency denervation for people with persistent low back pain when
non-surgical treatment has not worked, AND the main source of pain is thought to come from
structures supplied by the medial branch nerve, AND the person’s pain is limiting their quality
of life.1
- Only perform radiofrequency denervation in people with persistent low back pain after a
positive response to a diagnostic medial branch block.1
- Radiofrequency denervation may be repeated if this gave the patient 12-16 months of pain
relief
- MRI is not necessary to aid diagnosis5
- Therapeutic facet joint injections are not recommended.
- Patients should typically be having physical rehabilitation simultaneously with radiofrequency
denervation treatment

References
1
NICE 2016 guidelines low back pain and sciatica in over 16s (NG59)
2
CKS Back Pain – Low (without radiculopathy) – April 2017.
3
Global Burden of Disease 2013
4
STarT guidance
5
National low back pain and radiculopathy pathway (2017)

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 MECHANICAL LOW BACK PAIN WITH NO LEG SYMPTOMS OVERVIEW

EARLY CLINICAL REVIEW Check for Red Flags

Assessment / recheck diagmosis (6)

LOW RISK OF DISABILITY (4) MEDIUM-HIGH RISK OF DISABILITY

(STarT tool can be used) (STarT as optional guide)

Self-Manage (4).
• Direct patient to self-
help information such Low Intensity
as the MSK Together Combined Physiotherapy
Website. Physiotherapy Exercise +/- Manual
• Patient to return to and Psychological Therapy (10)
clinician if symptoms Programme (10)
not improving.

MSK HUB TRIAGE

- Specialist electronic
OR face to face
Access Secondary Triage via Band 7 APP
Care Pain or BAND 8 ESP (9).
Management
Services for:
• Extra Guidance with
regards to assessment
and management.
• Consideration for
medial nerve root
branch blocks
• Re facet joint
Comprehensive Multi-
pain - consideration
for radiofrequency Disciplinary Physical
denervation see facet + Psychological
joint pain overview programme (PICs)
p.5/p.11) (12).

*Add-on Treatment options include:- FINAL OUTCOME:

• Improving access to Psychological Therapies Return
to work scheme (24), Community Gym Referral/
Discharge/Self-Manage
Weight management programme. (5).

Note - the numbers in brackets refer to the boxes within the National Low back Pain and Radicular Pathway (2017).

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DIAGNOSIS: LUMBAR RADICULOPATHY
TYPE OF
GUIDELINES
INFORMATION
Background Lumbar radiculopathy is defined in terms of symptoms (including pain and paraesthesia) and
information signs (including weakness) in the distribution of a spinal nerve root.
Nerve root pain can be due to many causes including disc herniation (90% of case), spinal
stenosis, spondylolithesis, neoplasm (rare) or infection (rare)1.
73% of radiculopathy patients report reasonable to major improvement in symptoms within 12
weeks1. A poorer prognosis has been documented in1:-
- Women - recovery is slower and the risk of an unsatisfactory outcome is greater than for
men.
- People who initially have greater functional impairment or pain.
- People with psychosocial risk factors

Subjective • Low back pain.

history • Possible tingling, numbness, shooting/burning pain, altered sensation usually unilaterally.
• Leg pain-radicular/radiate from low back into the leg towards or beyond the knee.
• Lumbar Stenosis is narrowing of the spinal canal and typical causes pain which is relieved
by flexion-based activities and worsened with extension based activities +/-spinal claudication
(bilateral calf pain, paraesthesia or numbness on walking).1

Physical Recommended physical examination techniques

Examination
• Full lower limb neurological examination to include the assessment of sensation, myotomes
findings
and reflexes. (patella/medial hamstrings/ankle jerk).
• UMN Assessment (choose from Plantar Reflex/Clonus/Rhombergs/Dysdiadochokinesia/
Finger-NoseTest/Heel-shin test/ multijoint movement looking for extensor pattern in upper or
lower limb/pronator drift/hoffmans/observation of initiation of co-ordinated movements such
as sit to stand, gait).
• Lumbar and hip Range of Movement.
Presentation -
• Muscle atrophy, Segmental motor deficit, Segmental sensory change, Hyporeflexia1
• Stenosis Presentation – symptoms low back pain/legs symptoms which may be provoked
with extension based activities and eased with lumbar flexion.1

Investigations • Do not routinely offer imaging for patients with radicular symptoms.1
• Consider imaging (i.e. Lumbar MRI) for radiculopathy only if the result is likely to change
management1.
• Imaging results should be assessed in relation to whether they correlate with the patient’s
examination findings. This will facilitate decision-making regarding ongoing management.2
• Imaging should be communicated to patients in a manner that facilitates appropriate self-
management strategies rather than maladaptive strategies or perceived frailty.

Conservative Treatment should facilitate excellent patient compliance with high-quality conservative
management management strategies; these could include:
• Shared decision-making.
• Reassurance/ Education regarding their condition and the aims of physiotherapy (consider
the use of different media to complement their individual learning style).
• Pain medication as required - Neuropathic pain relief/NSAID medications.

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DIAGNOSIS: LUMBAR RADICULOPATHY
TYPE OF
GUIDELINES
INFORMATION
Conservative Exercise +/- Manual therapy via Physiotherapy 2
management
• Take the patient’s specific needs and preferences into account when choosing the type of
exercise, whether it is in a group or individual setting.
• Encourage activity and address inactivity; bed rest is not recommended.
• Graded Exposure. Try to address psychosocial barriers such as fear-avoidance of activity/
unhelpful beliefs.
• Promote and facilitate return to work – consider the return to work scheme if the patient would
like additional support with this (box 24) 2.
• Goal setting (SHORT/MEDIUM/LONG). Give realistic time scales.
• Consider a referral into the Bfit programme (combined physical and psychological programme
when there are psychological obstacles to recovery such as anxiety.2)
• The band 7/8 clinicians can refer to the MDT Pain Management Service (PICs) when
there are psychological obstacles to recovery such as anxiety and depression, for example,
avoiding normal activities based on inappropriate beliefs about their condition or when
previous treatments have not been effective.
Add-on Treatment options
• The patient can also self-refer to the 4 IAPT services (Insight, Trent PTS, Turning Point, Let’s
Talk Wellbeing). This could be appropriate if there are psychological barriers to an
improvement in their symptoms.

Referral on to The patient should have had an MRI scan or CT scan if unable to have an MRI scan.2
secondary care Prior to referral:-
consultant/pain
• MRI report and imaging to be available
management
• Full medical history and medications to be available
services
• History/Examination – see above
• Assessment of severity of symptoms ▪
• Ask patient if tolerable, non-tolerable and whether improving, worsening or plateaued
• Outcome measures could include NPRS for leg/back pain, PSFS, EQ-5D, Oswestry Disability
Index (ODI).
Once referred to secondary care, the following non-conservative procedures can be considered
for people who have radiculopathy. These can only be considered if the MDT feel there is
‘possible’ concordant nerve compression or the nerve root compressed may be responsible for
the clinical findings: - 2
• Epidural injections/nerve root block (via Pain Management services)
• Spinal decompression (via surgical spinal teams)
Epidural injections/nerve root block may be considered for severe, non-controllable radicular
pain in prolapsed intervertebral disc early in the clinical course for symptom control (box 22) 2
Consider referral to PICs or for spinal opinion for acute radicular pain if:
• No response to appropriate physiotherapy and analgesia (8-12 weeks if non-tolerable
radicular pain which has been refractory to conservative treatment intervention, inclusing
NSAIDs and a trial of at least 2 neuropathic medications at therapeutic dose (see APC, NICE
(CG1733)
• Concordant MRI findings
• Very severe radicular pain, which is not controllable with analgesia or nerve root injection,
may require early surgery likely to be at the 1-3 week stage. Early surgery may also be
required if accompanied by major radicular weakness (motor power <3/5
• Later surgery may occur in patients with symptoms of fluctuating severity (box 23).2)
• Patients are appropriate for spinal referral if they would not decline surgery if offered

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 DIAGNOSIS: LUMBAR RADICULOPATHY
TYPE OF
GUIDELINES
INFORMATION
Referral on to Extra note:-
secondary care Note - Injections for central or foraminal stenosis (without disc herniation) are not approved.
consultant/pain Fusion surgery may still be considered as a necessary adjunct to another procedure performed
management for conditions other than non-specific low back pain, e.g. decompression for spinal stenosis with
services symptoms of claudication, radicular pain or other indication2.

References
1
NICE CKS Low Back Pain and Sciatica (2017).
2
NICE Endorsed National Low Back and Radicular Pain Pathway (2017).
3
NICE CG173

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 LUMBAR RADICULOPATHY OVERVIEW

Lumbar Radiculopathy
Assessment/Follow-Up – Check for Red Flags
Review Severity and current (6)
Management (8).

MSK Hub Assessment (19)

Access to Band 7 APP/Band 8 8 ESP
MSK Assessment .
• Imaging could be considered (not
routinely)
Conservative
Therapy (18)
• Information on
self-care.
• Core Therapies:
Exercise+/- Manual Non-Concordant
MRI results concordant
Therapy and/or Imaging. Shared
with presentation and
low-level CPPP decision-making. MSK
shared decision-making
programme. clinician discusses
with patient.
• Pharmacological results with patient.
(21)
Treatment. (20)
• Staged Return to
work (24)

Conservative
Therapy (18) Secondary Care
opinion for epidural/ Surgery indicated
nerve root block Secondary Care -
(Pain Management Refer to Surgical
Services- PICs) Unit (23)
+
Rehab (22)

Discharge/Self-
Management (5).

Note - the numbers in brackets refer to the boxes within the National Low back Pain and Radicular Pathway (2017).

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DIAGNOSIS: COCCYGEAL PAIN
TYPE OF
GUIDELINES
INFORMATION
Background Conservative treatment is thought to be successful in 90% of cases, and many cases resolve
information without medical treatment.
The incidence of coccygeal pain is unknown. Risk factors are thought to include obesity and
female gender (5 x more common).

Subjective • The person complains of localised pain over the coccyx or over the “tailbone”.
history • Symptoms could occur insidiously or through direct trauma.
• Aggravating factors could include prolonged sitting, leaning back when sitting, prolonged
sitting and rising to a standing position, sexual intercourse and/or defecation.

Physical • Symptom reproduction with pain on palpation of the coccyx.

Examination • Check for alternative diagnoses through neurological examination/assessment of functional
findings movement/lumbar range of movement.

Investigations • X-ray to assess for bony pathology/fracture.

• No other investigations would be typically required to aid the diagnosis of coccygeal pain.

Conservative Conservative treatment is thought to be successful in 90% of cases and many cases resolve
management without the person seeking medical treatment.
Treatment should be individually tailored to address any underlying barriers to improvement
- such as reduced sleep, anxiety/depression, catastrophisation, kinesiophobia, and reduced
physical activity levels.
Use a specially designed coccyx cushion, which can reduce the pressure on the coccygeal
region when sitting.
• Advice regarding regular movement - Avoid prolonged sitting whenever possible – try to
stand up and walk around regularly; leaning forward while seated may also help.
• Heat/Cold Therapy could be used.
• Pharmacological Management: Take over-the-counter painkillers (such as paracetamol,
ibuprofen)., Use of laxatives (medicines to treat constipation) if the pain is worse when the
patient tries to open their bowels.

Referral on to • Consider cortisone injections for coccygeal pain for patients in which good-quality
secondary care conservative treatment has not eased their symptoms.
consultant/pain • Surgery for coccydynia is usually only recommended when all other treatments have failed.
management It may involve removing some of the tailbone (partial coccygectomy) or occasionally all of it
services (total coccygectomy). It takes a long time to recover from coccygectomy, anywhere from a
few months to a year.

Prognosis Patient with coccygeal pain usually respond well to conservative management strategies.

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 DIAGNOSIS: OTHER SPECIFIC CAUSES OF LOW BACK PAIN
(E.G. SPONDYLOLISTHESIS)
TYPE OF
GUIDELINES
INFORMATION
Background • NICE CKS – “If an underlying cause for the low back pain has been identified, manage
information according to the specific diagnosis”1
• Spondylolysthesis, regardless of the type, can be preceded by spondylolysis, a fractured
pars interarticularis of the lumbar vertebrae.
• Spondyloysthesis can be asymptomatic and are graded as 1-4, with 4 being the highest
amount of translation.

Subjective • Varies depending on the specific cause of the low back pain.
history • Use subjective examination to aid diagnosis/lower suspicion of other causes e.g. vascular,
hip pain etc.

Physical - Varies depending on the specific cause of the low back pain
Examination - Use physical examination to aid diagnosis/lower suspicion of other causes e.g. vascular, hip
findings pain etc.

Investigations X-ray/MRI would be used to identify if suspicious of a specific cause for low back pain such as
spondylolisthesis. In adults with radiculopathy, MRI should be considered.

Referral on to Spinal Unit QMC recommendations - Persistent pain from specific cause (e.g.
secondary care spondylolisthesis) MUST have had pain clinic opinion first prior to any referral to the spinal unit
consultant/pain at QMC.
management
services If a specific cause for the back pain (>3/12) is possible on MRI – review diagnosis, and spinal
referral may be appropriate, but exclude other causes e.g. vascular, hip pain etc.)

Referral on to • Consider cortisone injections for coccygeal pain for patients in which good-quality
secondary care conservative treatment has not eased their symptoms.
consultant/pain • Surgery for coccydynia is usually only recommended when all other treatments have failed.
management It may involve removing some of the tailbone (partial coccygectomy) or occasionally all of it
services (total coccygectomy). It takes a long time to recover from coccygectomy, anywhere from a
few months to a year.

Prognosis Varies depending on the specific cause of the low back pain

References
1
NICE CKS Low Back Pain and Sciatica (2017).

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DIAGNOSIS: SPECIFIC CAUSE OF LOW BACK PAIN - OSTEOPOROTIC
FRACTURES
TYPE OF
GUIDELINES
INFORMATION
Background Osteoporosis
information
• Osteoporosis can affect men and women. Osteoporosis itself isn’t a key risk factor for pain
however it places the patient at an increased risk of fracture.
• Most common in postmenopausal women.
• 1: 12 men and 1:3 women over age 50 will suffer an osteoporotic fracture.
• Hip Fracture, risk of falls and osteoporosis are interlinked.
• Women who have suffered a fragility fracture (defined as fracture sustained from a fall from
standing height or less) are at increased risk of fracture fractures, independent of their bone
mineral density (BMD).
• Audit of clinical practice is required and audit tool available.
• Exclude other causes for spinal pain plus deformity, such as neoplasm, infection before a
diagnosis of osteoporosis can be made.

Subjective • Risk Factors for Osteoporosis:

history
• Fragility Fractures (more than 1)
• Patients who have sustained one or more fragility fractures should be a priority for
investigations and treatment of osteoporosis.
• Age – a significant increase in prevalence with each decade after 60.
• Gender – more female than male.
• Ethnicity – white women have a 2.5 times greater risk compared with Afro-Caribbean
women.
• Reproductive Factors – early menopause means higher risk.
• Family History – maternal, paternal and sister history; family history should not only include
the diagnosis of osteoporosis but also of presence of kyphotic thoracic spine and fractures
younger than 50.
• Weight - Below average BMI is associated with higher risk.
• Smoking - Men who smoke show greater loss of bone density at greater trochanter.
Female smokers have higher risk of hip fracture; level of risk declines with smoking
cessation but not until 10 years after quitting.
• Alcohol – Evidence is inconsistent regarding alcohol use.
• Exercise- Positive relationship between weight bearing exercise/activity on reduced risk of
osteoporosis. Therefore sedentary patients are proven to be at higher risk.
• Diet – inconsistent results on vitamin D and milk intake on reducing risk.
• Secondary causes – anorexia nervosa, chronic liver disease, celiac, hyperparathyroidism,
inflammatory bowel disease, male hypogonadism, renal disease, RA, long-term steroid
use, vitamin D deficiency.
Risk Assessment
• No specific tool to use.
• Those at highest risk: women, over age 60 with a family history.
• Secondary factors: Caucasian, early menopause, low BMI, smoking history, sedentary
lifestyle, long term (>3 month) history of steroid use.

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DIAGNOSIS: SPECIFIC CAUSE OF LOW BACK PAIN - OSTEOPOROTIC
FRACTURES
TYPE OF
GUIDELINES
INFORMATION
Physical Recommended assessment measures for osteoporosis by CSP
Examination
• BMI (height and weight).
findings
• Chest expansion at xiphisternum level.
• Cervical/thoracic deformity as measured by tragus to wall.
• Shoulder flexion angle with patient against wall (indirect thoracic spine extension).
• Lumbar spine range of movement (Shoeber’s extension).
• Some measure of strength and endurance should be included.
• Balance assessment – 1 leg stand or Tinnetti or other measure.
• Functional assessment - could utilise the Osteoporosis Functional Disability Questionnaire.
• Pain Assessment - such as the VAS.

Investigations Recommendations of investigative options (spinal):

• DXA
• Quantitative Computerized tomography (QCT).
DXA
• Most accurate for assessing BMD and hence diagnosis of osteoporosis.
• BMD of femoral neck + sex + age = used for estimated predictive of fracture rusk.
QCT
• Benefits – great detail.
• Disadvantages: high radiation dose and not always available.
Plain radiographs:
• Plain radiographs should not be used to diagnose or exclude osteoporosis.
• If plain film radiograph suggest “severe osteopenia” then a DXA is indicated.
• Can be used is vertebral fractures suspected as to do so would alter management (by
grading) and there is an established method for reporting these findings.
Quantitative US (QUS) of calcaneus cannot be used to diagnose osteoporosis or to target
treatment.

Biomechanical markers of bone turnover should have no role in the diagnosis of osteoporosis.

Conservative Everyone with Osteoporosis should be encouraged to increase dietary calcium intake
management and also partake in weight bearing exercise.
Aims of Treatment:
• Reduce the incidence of future fractures.
• Reduce fracture-related morbidity.
• Pain management
• Patient education.
• Improve psychological wellbeing.
• Improve muscle strength, balance and CV fitness.
• Reduce risk of falls.
• Improve balance.
Exercise
• Benefits: reduces falls risk, minimizes further BMD loss.
• Modes of exercise:
- High intensity strength training.
- Low impact weight bearing exercise.
- Water-based/land-based depending on severity and irritability of the pain and level of function.
- See CSP guidelines for further detail.

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 DIAGNOSIS: SPECIFIC CAUSE OF LOW BACK PAIN - OSTEOPOROTIC
FRACTURES
TYPE OF
GUIDELINES
INFORMATION
Conservative Calcium intake.
management
- Postmenopausal women should aim for dietary intake of 1000mg calcium per day.
- No evidence vitamin D supplements are needed for active people over age 65.
Ipriflavone – should only be used in conjunction with other interventions.
Pain Management
- Vertebral fracture can be pain free or significantly painful.
- Acute vertebral fracture management
• Main aim: early mobilization plus adequate pain control.
• RICE
• Simple analgesia up to opioids (advice from pain management service may be required).
• Hospital admission may be required.
• Calcitonin is not license in the UK but has been shown to be of benefit for acute vertebral
fractures for pain management.
Chronic Vertebral fracture management:
• Analgesia ladder.
• Back strengthening exercises should be considered.
• Psychological care is important – as sleep is often impaired.
• Consider trycyclic antidepressants for sleep and psychological needs.

Referral on to Consider escalation to secondary care (spinal unit QMC) if there are any red flags, high
secondary care severity of pain and/or a new fracture is suspected. Consider referral to pain management
consultant/pain services.
management
services Surgical Treatment Options:
NICE1 recommends Percutaneous vertebroplasty, and percutaneous balloon kyphoplasty
without stenting as options for treating osteoporotic vertebral compression fractures only in
people:
• who have severe ongoing pain after a recent, unhealed vertebral fracture despite optimal
pain management and
• in whom the pain has been confirmed to be at the level of the fracture by physical
examination and imaging.

Prognosis • In patients who have pain due to vertebral collapse due to osteoporosis and have balloon
kyphoplasty – these patients have improved pain control at 24 months but not necessarily
improved function.
• Early diagnosis and commencement of treatment results in fewer falls, fragility fractures and
improved quality of life measures.
• Early and adequate pain management results in fewer acute vertebral fracture morbidities.

References
2
NICE (2013)- Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for treating osteoporotic vertebral compression fractures (2013).
3
NICE CKS Osteoporosis (2017).
4
SIGN - The management of osteoporosis: a national clinical guideline (2013).

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WHEN TO ORDER IMAGING
• Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without radicular pain.
• Consider imaging only if red flags are suspected or if the result is likely to change management.
• Essential referral information for Lumbar MRI request:
o Site of radicular pain; Location of pain/suspected nerve root involved; Previous surgery; Suspicion of other
pathology e.g. spondylosis.
• The MRI department should be advised of any patient with an implanted metal device, so that the appropriate
safety assessment can be made. The majority of patients with implanted surgical metalwork such as hip or knee
replacements, orthopaedic metal plates and screws can safely undergo MRI, though it is often advised that unless
clinically urgent, imaging is not carried out in the immediate post-operative period. A delay of 6 weeks is considered
prudent.
• Most cardiac pacemakers are not MRI compatible. Many intracranial devices, clips, cochlear implants and intra-
spinal stimulators are also not compatible. Some cardiac valves and vascular implants are contraindicated, so all
devices need to be individually assessed by the MRI department.
• Imaging should be communicated to patients in a manner that facilitates appropriate self-management strategies
rather than maladaptive strategies or perceived frailty.

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MSK SERVICES PATHWAY - HIP PATHOLOGY
GPs to follow guidance offered within this pathway and where relevant refer using
Ardens templates and within remit of CCG Restricted and Not Routinely funded policy.

RED FLAG

• Septic arthritis • Neurological

Diagnosis to • Fractures • Hernia/Groin strain
monitor • Dislocations • Visceral referred pain
• Tumours

Medical Professionals seeing patients with

History & MSK complaints in primary care should be
Symptoms trained in assessing for alarming features and
red flags in all patients.

ASSESSMENT & DIAGNOSIS OF OTHER CONDITIONS

Red Flags Screening Inguinal Pathology

Septic Arthritis Sportsman’s Groin

Osteoarthritis (OA) Osteitis Pubis

Hip Impingement Stress Fractures

Metabolic Bone Disease Miscellaneous

Adductor Pathologies Nerve Pathology

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RED FLAG SCREENING: SPECIFIC FOR HIP PATHOLOGY
History & Consider Admission/Urgent referral if history of, or suspected malignancy investigate
Symptoms and refer as appropriate

SYMPTOMS SUGGESTIVE OF TUMOURS (PRIMARY OR METASTATIC):

• Past history of cancer – specifically those that metastases to bone including: breast,
prostrate, lung, kidney, thyroid, myeloma
• Deep, intense pain
• Nocturnal pain
• Pain worsen with weight bearing through affected joint
• Unexplained weight loss
• Mass presence
• Lymphadenopathy
• Unexplained limp
• Emergence of bony lump
• Fever
• Fatigue
• Atypical symptoms

SYMPTOMS SUGGESTIVE OF INFECTION OR SEPTIC ARTHRITIS

• Risk factors for sepsis include: Comorbidities of RA or OA, prosthetic joint, diabetic,
alcoholism, previous intra-articular steroid injection, ulcerated skin, IV drug use
• Systemic symptoms
• Constant pain
• Sudden onset of red, hot, swollen joint
• Please see more in ‘Septic Arthritis’ section below for more details
• Fever, not always present

SYMPTOMS SUGGESTIVE OF LOWER LIMB FRACTURE/DISLOCATIONS

• Trauma
• Pathological fracture - May result from the following low impact trauma in patients with the
following co existing diagnoses:
• Gauchers’ disease
• Paget’s disease
• Osteopenia/Osteoporosis
• Past history of cancer – specifically those that metastasise to bone
• Multiple myeloma
• Osteogenesis imperfecta

Examination SYMPTOMS SUGGESTIVE OF LOWER LIMB FRACTURE/DISLOCATIONS

findings
Infection suspected
• Red hot swollen joint
• Likely history of penetrative trauma but not always
Tumour
• Emergence of lump or bony mass
• Assess for lump or bony mass
• Differential diagnoses to consider: Paget’s disease, cold bone lesion (tuberculosis), benign
soft tissue lump (lipoma), benign bone tumour
• Escalate in line with 2 week Cancer Fast Track Pathways
Consider investigations: X-ray, MRI, Bloods

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DIAGNOSIS: SEPTIC ARTHRITIS
TYPE OF
GUIDELINES
INFORMATION
Background • This guideline is for acute onset (less than 2/52) of non-axial skeleton joints and for those
information older and 16 y/o
• Septic arthritis is associated with significant mortality
• Early diagnosis of septic arthritis is vital due to the potential for rapid and permanent
destruction of the joint, sepsis is another potential complication
• Incidence is higher in patients with pre-existing rheumatological conditions such as RA,
systemic lupus erythematosus (SLE), OA or those with joint prostheses
• In children the incidence is highest in those age less than 3 years
• The most commonly affected joints are knee and hip (especially in infants)
• Septic arthritis should be considered in any patient who presents with an acute mono-articular
inflammation

Subjective • Sudden onset of hot swollen, tender joint with less than 2/52 history of symptoms
History • Restricted ROM of the joint
• Hip and knee most common
• Presence or absence of fever is NOT a reliable indicator of an infected joint
• In some cases it can be poly-arthritic in nature
• Risk factors include: Comorbidities of RA or OA, prosthetic joint, diabetic, IV drug use,
alcoholism, previous intra-articular joint injection, ulcerated skin
Prosthetic Joint Infection
• Persistent joint pain and difficulty weight bearing with prosthesis loosening
• May occur within a year of surgery in a patient with history of post-operative wound infection; or
• May occur at a later stage with spread from an extra-articular site of infection, e.g. Pneumonia

Examination • Reduced hip ROM with severe pain

findings
Investigations • Synovial fluid (SF) aspiration is the principle diagnostic test for native joint septic arthritis
• In suspected hip sepsis, diagnostic aspiration will usually require the use of ultrasound or an
image intensifier (II)
• Blood cultures: will influence choice of antibiotics
• Baseline X-Ray is useful because most septic joints have pre-existing joint disease
• X-ray bone destruction is not seen until a later stage, approximately 10-14 days following
onset
• CT scan or MRI (may not be possible with certain prostheses) – useful for diagnosis of
abscesses, effusions and osteomyelitis
• If prosthetic joint in-situ, then urgent orthopaedic referral is required
Blood Cultures
• WCC, ESR,CRP, U’s and E’s, LFT’s
• Culture of aspirate if performed
Other Lab Tests
• If history suggests genitourinal or respiratory origin of infection – take appropriate swabs
Imaging
• Plain films will not detect initial changes but will be useful for comparative reasons
• MRI/CT is suspecting osteomyelitis

Conservative IF HIP SEPSIS IS SUSPECTED, A&E ADMISSION IS REQUIRED

management
• Patients should be admitted to hospital if sepsis if suspected and surgical intervention may be
required, IV antibiotics

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DIAGNOSIS: SEPTIC ARTHRITIS
TYPE OF
GUIDELINES
INFORMATION
Referral on for • Urgent referral to orthopaedic surgeon / on-call orthopaedic via A&E
secondary care • Delayed diagnosis or inadequate treatment can result in changes to joint services, delay in
opinion: antibiotics

DIAGNOSIS: OSTEOARTHRITIS (OA)

TYPE OF
GUIDELINES
INFORMATION
Background • Osteoarthritis refers to a clinical syndrome of joint pain accompanied by varying degrees of
information functional limitation and reduced quality of life
• Although pain and reduced function can be important consequences of OA, structural
changes often occur without accompanying symptoms

Subjective • Reports of moderate pain in the lateral or anterior hip/groin/thigh region

History • Pain on weight bearing; the pain can refer to the knee region
• Stiffness - usually less than 30 mins of early morning stiffness and after a period of inactivity
is common
• Often worse whilst exercising and at the end of the day
• Joint may feel as though it does not move as well / stiff
• Symptoms can vary with painful times followed by less or pain free times
• Pain may be constant with everyday tasks become increasingly difficult
• Joint contractures may be present in advanced cases
• Outcome measures can be used as a guide to severity of OA e.g. Oxford Hip Score

Examination • Limited passive range of motion of flexion, abduction, internal and external rotation compared
findings to less painful side
• Exclude spinal pathology
• Exclude infection
• Leg length discrepancy
• Trendelenburg gait pattern
• Muscle atrophy, especially gluts and quads

Investigations • Diagnosis of Hip OA needs to be made on a combination of clinical, symptomatic and

radiology findings
• Joint space narrowing along with other radiographic features, including, osteophytes and
subchondral sclerosis on plain film radiographs can be considered as a definitive diagnosis
• MRI is not indicated for OA Hip

Conservative • Aims of conservative treatment for OA of the hip are as follows:-

management • Reducing joint pain and stiffness
• Maintaining and improving joint mobility
• Reducing physical disability and handicap
• Limiting the progression of joint damage
• Educating patients about the nature of the disorder and its management

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DIAGNOSIS: OSTEOARTHRITIS (OA)
TYPE OF
GUIDELINES
INFORMATION
Conservative Core treatments include: (NICE)
management
• Patient Education - Healthcare professional should offer verbal and written information to all
people with OA to enhance their understanding of the condition and its management, and to
counter misconceptions, such as that it inevitably progresses and cannot be treated
• Exercise - Exercise should be a core treatment for people with OA irrespective of age,
comorbidity, pain severity or disability. Exercise should include: Local muscle strengthening
and general aerobic fitness. Water exercise and hydrotherapy may be an option
• Weight loss advice - Self-referral available
Adjuncts: Non-pharmacological treatments
• Clinicians should consider use of manual therapy procedures to provide short term pain relief
and improve hip mobility and function in patients with mild OA hip
• Walking aids can reduce pain in OA hip patients when used in contralateral hand
• Advice regarding appropriate footwear, including shock absorbing properties
• Heat/warmth can be used to ease symptoms
• TENS can help with short term pain relief control
Adjuncts: Pharmacological treatments
• Healthcare professional should consider advising paracetamol for pain relief in addition to
core treatments. Regular dosing may be required
• Paracetamol and/or topical non-steroidal anti-inflammatory drugs (NSAIDS) should be
considered ahead of oral NSAIDS, COX-2 inhibitors or opioids (discussion with Pharmacist /
GP indicated)
• If paracetamol or topical NSAIDS are insufficient then additional analgesics can be
considered. Risks and benefits should be considered
Intra-articular injections
• Intra-articular (IA) corticosteroid injections should be considered as an adjunct to core
treatment for the relief of moderate to severe pain in people with mild-moderate OA
• Referral to orthopaedic surgeon is required if IA injection to hip is to be considered

Referral on for REFERRAL INTO MR SRINIVASAN’S COMMUNITY SURGICAL HIP CLINIC AT AHWBC
secondary care
opinion The patient can be referred into Mr Srinivasan’s clinic if they meet the following criteria. The
APP should keep this clinic in mind when triaging:
• Has had an X-ray in the past, which shows moderate or severe degenerative changes at the
hip (pelvic or hip X-ray)
• If new imaging is indicated please request a HIP X-RAY with a KING MARK TEMPLATE
• ASA1 or 2 patient – essentially look medically well from the MED Q on SystmOne (can have
comorbidities but these are controlled)
• APPs can refer to Mr Srinivasan’s clinic from paper triage, even if they are unsure if the
patient is ASA2 or ASA3 as this is sometimes difficult to determine at paper triage
• The APP should make it clear in the task to MSK admin if booking in from paper triage:
“Secondary Care - Hip; appropriate for Mr Srinivasan’s community hip clinic at AHWB”
• Admin will arrange a C+B appointment away from AHWB if the patient prefers to go
elsewhere. The benefit to the patient is that they can be assessed and operated on in a very
timely manner (less than 2 weeks in many cases); keep this clinic in mind when triaging

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DIAGNOSIS: OSTEOARTHRITIS (OA)
TYPE OF
GUIDELINES
INFORMATION
Referral on for Surgical Treatment
secondary care
opinion • Patients with hip OA who are not obtaining pain relief or functional improvement with
conservative means despite medication and non-pharmacology could be considered for joint
replacement
• Shared decision making discussion with the patient and a prior approval form completion is
required
• Most common indication for a THR is degenerative arthritis (OA) of the hip joint. Other
indications include RA, injury, bone tumours, avascular necrosis of the femoral head
• THR is universally recommended and is generally accepted as reliable and appropriate
surgical procedure to restore function and improve quality of life
• Minimal invasive surgery has been advocated, this reduces incision size, tissue trauma,
blood loss and post-operative pain.
Higher age, more preoperative pain, musculoskeletal co-morbidities, such as low back pain
in a non-operated hip can predict a poorer outcome following THR
Contraindications/precautions to elective hip surgery
• Current infection of the hip
• Other sites of infection
• Severe vascular disease
• Patients unwillingness to undertake risks outlined
• Poor general health
• History of osteomyelitis
• Morbid obesity

DIAGNOSIS: HIP IMPINGEMENT

TYPE OF
GUIDELINES
INFORMATION
Background • Hip impingement syndrome, is a result of an abnormality in the femoral head, acetabulum
information or both
• Femoral Acetabular Impingement (FAI) can be CAM or Pincer
• Impingement can be caused by catching/impinging of the abnormally shaped femoral head
into the acetabulum during a forceful motion (especially flexion) or as a result on contact
between the acetabular rim and the head-neck junction
• It is unclear but it may lead to the development of OA
• Other problems that cause hip impingement include, Perthes disease, Coxa Vara and Slipped
Capital femoral epiphysis

Subjective • Symptoms may include restriction of movement, “clicking of the hip joint and pain
history • May be exacerbated by sporting activities, hip flexion activities, or prolonged sitting
• Pain described as a dull ache
• Onset often insidious
• Mainly anterior hip discomfort but patients can also complain for lateral and posterior pain
• May indicate location of pain by gripping the lateral hip just above the greater trochanter
between the abducted thumb and index finger, known as the “C” sign - SEE HERE
• Lumbar spine needs to be assessed, as well as other conditions/medications that manifest
as musculoskeletal problems.

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DIAGNOSIS: HIP IMPINGEMENT
TYPE OF
GUIDELINES
INFORMATION
Examination • Observe gait pattern, glute medius weakness
findings • ROM often reduced into deep flexion and internal rotation
• 90 degrees of flexion with combined internal rotation produces pain and sensation of a catch/
impinging feeling
Impingement tests can also be used, the hip is flexed to 90 degrees and then adducted and
internally rotated, positive test is sharp sudden pain in the hip. Tests often re-produce the
patient’s symptoms.

Investigations • X-Ray of the pelvis is indicated for persistent hip pain. It may demonstrate focal bone
pathology, erosive joint changes and/or dysplasia.
• They should include standard AP as well as a cross-table horizontal beam
• Findings of Dysplasia MUST be clinically correlated to the patient
• MRI is widely accepted as the best investigation for further evaluation of the hip.
This is best performed with intra-articular contrast (MRA)

Conservative • The management of hip impingement begins with a trial of conservative measures, including
management activity modification
• NSAIDS can be useful in patients with acute onset

Referral on for PRIOR TO REFERRAL TO SECONDARY CARE - ENSURE THE LUMBAR SPINE HAS
orthopaedic BEEN RULED OUT / TREATED AS A SOURCE OR CAUSE OF SYMPTOMS.
opinion
Surgery can either be arthroscopic or open with the aim being to improve hip ROM and alleviate
femoral abutment against the acetabular rim.
N.B. Prior Approval Form is required
Dysplasia
Age <30 - Periacetabular Osteotomy could be considered - an arthroscopic procedure to
treat hip dysplasia, which can be completed if the patient is under 30 years of age for joint
preservation
Age 30-50 -Window for hip preservation surgery is lost; therefore intra-articular injections
are warranted prior to any hip surgery. This aims to treat the symptoms in combination with
Physiotherapy.
Age 50> - injections are possible but not indicated if surgery is indicated, due to the increased
risk of infections. Early surgical intervention is therefore indicated.
Labral lesions are debrided using a shaver or radio-thermal device:
• Patients not responding to conservative measures
• For open procedures there is some evidence of short term pain reduction but it is not clear if
the procedure slows degenerative changes

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* For information only: GP management is indicated in all cases

DIAGNOSIS: METABOLIC BONE DISEASE*

TYPE OF
GUIDELINES
INFORMATION
Background • Metabolic bone disease is the term used to describe a range of conditions including:-
information • Osteoporosis
• Paget’s disease
• Osteomalacia
• Osteogenesis Imperfecta (OI) Brittle Bone disease
• They are all diseases which cause bones to become fragile and break without too much force
• Osteoporosis is a progressive disease in which the micro-architecture of bone is disrupted
with a consequent increase in bone fragility and susceptibility to fracture
• Such fractures are termed fragility fractures and often result from low energy events such as
a fall
• Paget’s disease is an condition in which there is a marked increase in bone turnover in
parts of the skeleton resulting in the development of structurally weak abnormal bone with
and increased risk of pain, fracture, deformity, osteoarthritis of the large joints
• Osteomalacia is a condition where there is a deficiency of mineral with the bone itself. This
lead to bone pain, deformity and easy fracture. Common cause is Vitamin D deficiency

Subjective • Osteoporosis; in the absence of fracture is asymptomatic and often remains undiagnosed
history • Paget’s can lead to bone pain and deformity which usually responds to appropriate treatment
Refer to Clinical Knowledge Summaries Guidelines

Investigations • Consider dual energy X-Ray absorptiometry to assess bone mineral density (DXA)
• Patients with kyphosis or loss of height should have lumbar spine imaging either by DXA or
lateral lumbar spine X-ray to examine for fractures
Initial blood tests include:
• Urea and Electrolytes
• LFT’s
• ESR (Consider investigations for myeloma if raised)
• Calcium, phosphate and alkaline phosphatise
• 24hour urinary calcium excretion
• Thyroid function tests
• Vitamin D3 levels
• Parathyroid hormone concentration

Conservative Before initiating therapy it is important to identify causes of secondary osteoporosis such as:-
management
• Hyperparathyroidism
• Alcohol abuse
• Thyroid disease
Non Pharmacological
• There is evidence that weight bearing exercise improves bone health
• Exercises designed to improve muscle strength and balance when maintained regularly over
time have been shown to prevent falls
• Having healthy, balanced diet that includes sufficient quantities of calcium and other vitamins
and minerals is essential to create healthy bones
• Having a healthy body mass index is also important, as being over or underweight
• Very low Vitamin D levels leads to osteomalacia whilst reduced levels may contribute to
osteoporosis
• It is possible to maintain healthy levels of Vitamin D by 15 – 20 minutes daily exposure of the
face and arms to sunlight without sunscreen during summer months or by taking supplements
• Other lifestyle factors also contribute to bone health, smoking leads to poor bone health as
well as excessive alcohol intake
• Falls prevention information should be given
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* For information only: GP management is indicated in all cases

DIAGNOSIS: METABOLIC BONE DISEASE*

TYPE OF
GUIDELINES
INFORMATION
Conservative Pharmacological
management
• Women over 75 who have had a fracture should be offered appropriate bone sparing
treatment according to current NICE guidelines

Referral on for • Postmenopausal women with an initial fracture are at substantially greater risk of subsequent
secondary care fractures
opinion • After a hip fracture, a high proportion of women are permanently unable to walk independently
or to perform other ADL’s
• Hip fractures are also associated with increased mortality

DIAGNOSIS: ADDUCTOR PATHOLOGIES

TYPE OF
GUIDELINES
INFORMATION
Background • Common in sports with sudden changes in direction
information • Adductor longus is the one most commonly involved

Subjective Adductor Strains

history
• Onset usually acute and is generally well localised either to the belly of the adductor longus,
proximal musculotendinous junction or tendon near the origin on the inferior pubic ramus
(the enthesis)
• Need to distinguish between strain of a healthy muscle compared to the strain of a muscle
that has adaptive changes / signs of tendinopathy
• May be local tenderness, pain on passive abduction, pain on resisted adduction or combined
flexion/adduction
Adductor tendinopathy
• May be primary or secondary condition of adductor muscle strain
• Presents with proximal groin pain, which has a tendency to subside with a good warm up,
decrease with gentle activities but may progress with increasing stress
• Can limit activity in latter stages
• Pain may migrate to contralateral groin or suprapubic region
• May be local tenderness over the adductor origin and over the pubic tubercle
• Pain on passive hip abduction and resisted hip adduction
MEN MAY REFER TO TESTICULAR PAIN - THIS MUST BE INVESTIGATED AND RULED
OUT AS A CAUSE BY THEIR GP

Examination • Pain on exercise in groin area

findings • Local tenderness
If patient complains of testicular pain or testicular referral pattern – GP examination is indicated.

Investigations • Ultrasound scan can look for muscle tears and tendinopathy
• MRI Pelvis - include potential diagnosis of ‘adductor pathology’ in clinical information

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DIAGNOSIS: ADDUCTOR PATHOLOGIES
TYPE OF
GUIDELINES
INFORMATION
Conservative Adductor Pathology
management
• Physiotherapy
• No early stretches
• RICE
• Gentle ROM to onset of pain, gentle massage to decrease pain/spasm
• Unloading, strapping
• Increase stretching, strengthening
• Stabilising exercises
• Progress rehab to shuttles, change of direction
Adductor Tendinopathy
• Physiotherapy
• Rest, ice
• No early stretching
• NSAIDS
• Eccentric loading programmes

Referral on for • May respond to steroid injection (USGI not indicated)

orthopaedic • PRP injections (Prior Approval Form required)
opinion • Surgical - adductor release as last resort

DIAGNOSIS: INGUINAL PATHOLOGY (HERNIA)

TYPE OF
GUIDELINES
INFORMATION
Background • Inguinal and femoral hernias can be defined as herniation of the bowel through the inguinal
information ring or femoral canal, secondary to incompetence of the musculature of the posterior inguinal
wall
• They may cause diffuse groin pain
• Inguinal hernias can be direct or indirect and they are graded as Type I, 2 3A, 3B, 3C or 4
depending whether they involved normal size internal ring, dilated inguinal ring, encroaching
on the inguinal floor, femoral hernia or recurrent
• Small hernias may become painful as a result of exertion

Subjective • Suprapubic pain with a characteristic dragging sensation to one side of the lower abdomen
history aggravated by increased intra-abdominal pressure (IAP)
• Aggravated by coughing and sneezing

Examination • Can reveal occasionally an obvious swelling

findings • May be a cough impulse

Investigations • Ultrasound may be able to detect coupled with a Valsalva manoeuvre

Conservative • Treatment usually consists of surgical correction which can be laparoscopic or open using a
management synthetic mesh

Referral on for • For consideration of surgery if hernia is suspected

secondary care • Referral to ‘General Surgery’
opinion

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DIAGNOSIS: SPORTSMAN’S GROIN
TYPE OF
GUIDELINES
INFORMATION
Background • There are often many different descriptions for the Sportsman’s groin; Conjoint tendon injury,
information Gilmore’s groin or Posterior abdominal wall dysfunction
• It refers to a variety of injuries involving the inguinal region and usually involves a tear at the
external oblique (EO) or of the EO aponeurosis and superficial inguinal ring
• Defect in the posterior wall is generally thought to be in the region of the conjoint tendon
• Pain often flares with activity and does not hurt when inactive
• Prevalence especially in athletes with chronic groin pain is reported to be as high as 80%

Subjective • Posterior wall/conjoint tendon area is particularly vulnerable as it is a transition zone for
history changes in collagen and tissue type
• It is often a pivot point for different forces
• Muscle fibres of the transverse, internal oblique that insert along the pectineal line unite to
form the conjoint tendon
• It is at this point that injuries often occur
• Repetitive stretching or sudden intense force can lead to their separation from the inguinal
ligament
• Can also occur with repeated micro-trauma and overload

Examination • Can be difficult to detect on physical examination

findings • They often occur with co-existing pathologies like, Osteitis pubis and adductor tendinopathy
• Present with groin pain
• Patients can describe vague insidious onset of deep groin pain usually the pain is unilateral
over the lower abdomen and may extend into upper thigh, dull ache may radiate to scrotum,
hip and back
• Aggravated by cough, sneeze
• Aggravated also by sit ups, kicking, sprinting
• Relieved by rest but can recur with exertion despite analgesia, physiotherapy and rest
• Can be associated muscle spasm and often guarding
• It is not usually possible to palpate the defect and resisted adduction may elicit pain but that
may be due to co-existing conditions such as adductor tendinopathy
• Tenderness over conjoint tendon and pubic tubercle is common and can be exacerbated by
sit-ups

Investigations • Ultrasound / MRI can be used but they can be negative therefore don’t request until
discussed with Consultant

Conservative • Definitive treatment is often surgery

management • Rehabilitation post-surgery can vary depending on the surgeon and the amount of re-
enforcement
• Avoid sharp sudden movements
• Isometric initially then progress to concentric then eccentric
• Walking ,jogging and sports specific will depend on surgeon
• Long term conditioning, flexibility and anterior/posterior slings

Referral on for • Consultant Triage Clinic indicated for opinion

secondary care • If surgical opinion required
opinion

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DIAGNOSIS: OSTEITIS PUBIS
TYPE OF
GUIDELINES
INFORMATION
Background • Condition involves inflammatory reaction affecting the Pubic Symphysis but can involve other
information structures as the condition progresses
• The reaction develops in response to overuse when load is placed on the pubic bones
• Generally self-limits with rest and reduced activity
• Can occur in conjunction with groin strains due changes and alterations in biomechanics
• Diagnosis can be challenge, can include muscle strain, tendinopathy, pelvic instability

Subjective • Insidious onset of groin pain, which can be felt in the adductors, anterior thigh, or low
history abdomen
• Symptoms can be vague and are often worse with exercise such as twisting and turning
• NSAIDS often help but do not give permanent relief. Short periods of rest reduce the severity
of the symptoms but on resumption of normal sporting activity the pain often returns to the
same intensity
• The condition is often progressive in nature until symptoms may prevent participation in activity

Examination • Clinical tests can vary from patient to patient

findings • Pain reproduction can be from resisted sit ups, resisted hip flexion, adductor squeeze test
• Pelvic and lumbar ROM may be limited
• May be reduction in hip internal rotation
• Can be pain and/or muscle guarding on passive hip abduction, FABER or Thomas test
• Tenderness can be felt in the adductors, rectus abdominus and pubic symphysis

Investigations • X-rays can show pubic symphysis irregularity, reactive sclerosis, pubic widening
• Bone scan and reveal local uptake over the pubic tubercles
• CT scan is the most sensitive (Consultant request)

Conservative • Rest is often the only treatment, however it may be that an active approach with pelvic and
management core stabilisation may be the preferably
• Gradual progression of training load depending on the patient is the main focus
• Maximise ROM of hips and pelvic biomechanics
• Rehabilitation model should be based on unloaded painful structures, regaining pain free
function, initiate core program, length/strength of muscles
• Progression to running, kicking, turning and twisting

Referral on for • Failure to progress after 6-12 months of conservative management

secondary care
opinion

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DIAGNOSIS: STRESS FRACTURES
TYPE OF
GUIDELINES
INFORMATION
Background • Repetitive micro-trauma/overuse
information • Sudden or rapid increase in training load
• Poor training surfaces – too hard or cambered
• Females, early training (premenarchal)
• Biomechanical abnormalities
• Dietary problems

Subjective • Pain usually develops during exercise and can be poorly localised.
history • Pain will eventually prevent exercise

Examination Stress fractures of the NOF

findings
• May be associated with tight muscles as they become fatigued because of intense training
• Presentation is of gradual onset of groin pain, poorly localised aggravated by activity and
weight bearing
(Femoral stress fractures are rare)
Stress fractures of Pubic Rami
• Occur occasionally in distance runners and it is important to differentiate from adductor
problems
• Usually a history of overuse with pain referral into the buttock, groin and thigh
• Treatment usually consists relative rest from aggravating activities until pain / localised
tenderness has resolved
• Fitness can be maintained with physiotherapy, cycling or swimming
• Biomechanics should be addressed
Avulsion fractures
• More often seen in skeletally immature athletes, usually between ages of 14-17
• Occur most commonly at the apophasis where the tenoperiosteal junction
• Common sites are the origin of the Sartorius at the ASIS, Rectus femoris, hamstrings at
ischial tuberosity, lesser trochanter at insertion of iliopsoas
• Occurs when muscle is either forcefully stretched beyond is freely available ROM
• Common presentation is sudden onset of pain, localised swelling, tenderness, limitation of
movement
• X-ray can confirm diagnosis
• Treatment of rest, ice, elimination of tension and load at the fracture site, decreased weight
bearing, ROM exercises, strengthening as pain settles

Investigations • X-ray is generally unremarkable.

• CT scan or MRI is required for diagnosis

Conservative • Treatment usually consists of rest from aggravating activities and protective weight bearing if
management needed
• Usually resolves but physiotherapy is required to work on biomechanical factors
• See above for individual fractures

Referral on for • Failure to progress after 6 months of conservative management

secondary care
opinion

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DIAGNOSIS: MISCELLANEOUS
TYPE OF
GUIDELINES
INFORMATION
Background Greater Trochanteric pain syndrome (trochanteric bursitis)
information
• Pain localised to lateral aspect of the hip, can radiate down lateral side of the thigh
• Aggravated by activities such as stairs, going up and down stairs
• Site of tenderness is often immediately above the greater trochanter
• It is estimated that greater trochanteric pain syndrome resolves in over 90% of people with
conservative measures
Conservative management:
• Referral through to physiotherapy
• Rest, NSAIDs, stretching of glut med, pelvic stability, correction of biomechanical
abnormalities, weight loss if appropriate
• Peri-trochanteric injections in primary care can help into area of maximal tenderness
• Ensure that the lumbar spine has been assessed and has been eliminated as a cause of the
symptom
• If symptom persist for 3 to 4 months despite appropriate conservative management/CSI
consider referral on for orthopaedic opinion- further investigation may be required
Please see : https://cks.nice.org.uk/greater-trochanteric-pain-syndrome-trochanteric-bursitis
Gluteus Medius Tears / Tendinopathy
• Gluteal tendinopathy is the most common hip tendonitis
• The most common onset of gluteal tendinopathy is due to poor hip and gluteal muscle
control that leads to overstressing of the gluteal tendons, causing pain and hip-pelvis instability
• This weakness or insufficiency of gluteus medius can produce LBP / Hip / Groin / Knee Pain
Conservative management:
• Referral through to physiotherapy
• 3 to 4 months of appropriate conservative management addressing pain, AROM of the
lumbar spine and hips, strengthening programme for whole lower limb kinetic chain and core
• If symptoms persist despite appropriate treatment may need to rule out facet joint L5/S1 OA
or Pars Defect first (MRI Lumbar Spine)
• US guided injection may be appropriate if symptoms persist despite appropriate conservative
management. Referral on for an orthopaedic opinion will be required for this
Iliopsoas Bursitis
Iliopsoas bursitis is an inflammation of the bursa located beneath the iliopsoas muscle. This
muscle is located in front of the hip. A bursa is a fluid-filled sac between bones, muscles,
tendons, and skin. It provides cushion between tissue to decrease friction and irritation.
Iliopsoas bursitis can make it difficult to walk and exercise
• Pain may be experienced from the bursa at the attachment of the muscle at the lesser
trochanter or in the anterior thigh
• Symptoms can be exacerbated by:
• Walking up a flight of stairs
• Exercising
• Extending your leg
• Rising from a seated position
• May be aggravated by hip flexion

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DIAGNOSIS: MISCELLANEOUS
TYPE OF
GUIDELINES
INFORMATION
Background Conservative management:
information
• Referral through for physiotherapy to strengthen and stretch hip flexors muscles
• Over-the-counter anti-inflammatory medications if appropriate
• Corticosteroid injection into the bursa to relieve inflammation- this will need to be ultrasound
guided and further investigations may be required prior to this
• If no response with 3 months of appropriate conservative management refer for orthopaedic
opinion
Haematomas
• Commonly affect the thigh muscles and can occur after a collision with a blunt object
• Can be painful but don’t normally limit function
• After a severe force often get bleeding into a confined space which can result in significant
pain, muscle spasm and reduced ROM
• Complications occur if there is increased pressure in the compartment leading to decreased
blood flow
• Treatment – RICE, walking aid’s may be required, gentle active and passive ROM to help
reduce muscle spasm
Myositis Ossificans
• Characterised by the formation of local heterotrophic bone in soft tissue, may be due to blunt
trauma
• Soft tissue mass may be evident shortly after the injury, calcification may be seen 3-4 weeks
on x-ray
• Mass is usually well defined 6-8 weeks post injury
• Can sometimes last 6 months and then subside
• Treatment: avoid aggravating activities, gentle ROM to prevent contractures. Graduated
strengthening as pain allows
• Physiotherapy modalities, such as massage and excessive loading can aggravate

DIAGNOSIS: NERVE PATHOLOGY

TYPE OF
GUIDELINES
INFORMATION
Background Obturator Neuropathy
information
• It is fascial entrapment of the obturator nerve as it enters the adductor compartment
• Pathology, distinct fascia can be found deep to the adductor longus and pectineus overlying
the anterior portion of the obturator nerve.
• The arterial blood supply to the adductor muscles is related intimately to the nerve along with
thickening of the fascia
• These changes can result in nerve entrapment syndrome
• It can be a diagnostic challenge as it may mimic Osteitis pubis and adductor tendinopathy
• It is important to distinguish between post-exercise pain and altered neurology

Subjective • Chronic groin pain in athletes

history • Pain onset often during or post exercise
• Altered sensation or neural symptoms reported

Examination • Exercise related groin pain in the area of the proximal groin
findings • May have associated weakness
• No pain at rest but may get pain on passive abduction or resisted adduction
• Weakness of the adductor muscles is often reproduced following exercise as well as
numbness over the distal thigh
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DIAGNOSIS: NERVE PATHOLOGY
TYPE OF
GUIDELINES
INFORMATION
Investigations • EMG shows changes in the adductor muscles

Conservative • Physiotherapy, neural glides, massage, adductor soft tissue release, spinal mobs
management

Referral on for • If no improvement refer to Triage Clinic or Secondary Care for opinion
secondary care • Diagnostic Nerve Block (USG) by Orthopaedics not Pain Management
opinion • Surgery to free obturator nerve may be considered

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MSK SERVICES PATHWAY - KNEE PATHOLOGY
GPs to follow guidance offered within this pathway and where relevant refer using
Ardens templates and within remit of CCG Restricted and Not Routinely funded policy.

RED FLAG

• Septic arthritis • Acute locked knee

• Dislocations • Extensor mechanism
Diagnosis to • Tumours disruption
monitor • Infections/Traumatic Swollen • Fractures / Other
Joint • Neurological lesion

Medical Professionals seeing patients with

History & MSK complaints in primary care should be
Symptoms trained in assessing for alarming features and
red flags in all patients.

Injury Consider admission/urgent referral

ASSESSMENT & DIAGNOSIS OF OTHER CONDITIONS

Red Flags Screening PFPS / AKP

Osteoarthritis Patella dislocation / Subluxation

Meniscus Injury – Acute ITB Syndrome

Meniscus – Degenerative Baker’s Cyst

Ligament Injury Referred pain from Hip / Lx

Chondral Injury / Defects Other Soft Tissue

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 RED FLAG SCREENING: SPECIFIC FOR KNEE PATHOLOGY
History & Medical Professionals seeing patients with MSK complaints in primary care should be trained in
Symptoms assessing for alarming features and red flags in all patients.

CONSIDER ADMISSION/URGENT REFERRAL IF:

• History of cancer or suspected malignancy, investigate and refer as appropriate.
SYMPTOMS SUGGESTIVE OF TUMOURS (PRIMARY OR METASTATIC, BONE
TUMOUR, SOFT TISSUE SARCOMA, METASTASES, HAEMATOLOGICAL CANCER OR
NEUROBLASTOMA)
• PMH of cancer- Bony metastases develop in 2/3 of patients with cancer-specifically those
that metastasise such as; prostate, breast, lung, kidney, thyroid, myeloma
• Unexplained weight loss
• Non-mechanical night pain
• Deep, intense pain
• Increasing, persistent or unexplained bone pain, tenderness or swelling, especially if it is not
in the knee joint itself but adjacent to the knee.
• Sudden onset of pain (may indicate a pathological fracture but can also occur in
osteonecrosis)
• Pain worse at night/nocturnal pain
• Fever
• Mass presence
• Lymphadenopathy
• Pain that is worsened by weight bearing through affected joint
• Unexplained limp1
• Emergence of bony lump1
• Fatigue1
• Atypical symptoms
• PMH of sexual infection/lower GI infection
If there is a history of cancer, needs to be referred urgently for specialist assessment in line with
2 week fast track cancer pathway, with x-ray requested - AP, lateral, sky line, possibly full length
femur.

SYMPTOMS SUGGESTIVE OF INFECTION OR SEPTIC ARTHRITIS OR OSTEOMYELITIS

• Risk factors for sepsis include: Comorbidities of RA, or OA, prosthetic joint, low
socioeconomic level, diabetic, alcoholism, previous intra-articular joint infection, ulcerated
skin, IV use
• Constant pain
• Sudden onset, red, hot, pyrexia or red-hot joint, reduced movement of the joint especially if:
- Significant swelling appeared acutely, over less than 24 hours
- Only one joint is affected, although in up to a fifth of people with septic arthritis, more than
one joint is affected.
• Knee pain is severe, or in people with pre-existing joint disease e.g. OA, RA, out of proportion
to usual symptoms
• High inflammatory markers
• Systemic symptoms
• Fever not always present; nausea, vomiting, systemically unwell are also possible
• Risk factors for infection: recent knee surgery in particular knee replacement, RA, IV drug
use, immunosuppression e.g. diabetes, use of long term corticosteroids, alcoholism, or
adjacent skin infection / ulceration

1
Map of Medicine – Bone sarcoma suspected 2010

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 RED FLAG SCREENING: SPECIFIC FOR KNEE PATHOLOGY
History & RED FLAGS FOR INFLAMMATORY POLYARTHRITIS
Symptoms
• Persistent synovitis, indicated by:
- Pain that is worse at rest or during periods of inactivity
- Joint swelling, tenderness and warmth - giving a ‘boggy’ feel on palpation
- Stiffness in the morning and after inactivity that lasts more than 30 minutes
• Synovitis affecting other joints - symmetrical synovitis of the small joints of the hands and feet
is typical in rheumatoid arthritis
• A history of psoriasis, inflammatory bowel disease, or iritis (uveitis)
Suspected inflammatory condition, investigate and refer to Rheumatology

SYMPTOMS SUGGESTIVE OF LOWER LIMB FRACTURE / DISLOCATIONS

• Trauma
• Bruising / effusion
• Pathological fracture - may result from a low impact trauma in patients with the following
co-existing diagnoses:
• Past history of cancer - specifically those that metastasise to bone
• Multiple myeloma
• Osteopenia / osteoporosis
• Osteogenesis imperfecta (brittle bone disease)
• Gaucher’s disease
• Paget’s disease

SPONTANEOUS OSTEONECROSIS OF THE KNEE (SONK) / AVASCULAR NECROSIS (AVN)

• Not very common
• Most patients will have symptoms out of proportion to X-ray findings
• Commonly related to pain on palpation of the femoral condyle
• MRI required - once it is reported as AVN or SONK - needs URGENT Orthopaedic Elective
Clinic Referral
• Large number of SONK incidences are believed to be associated with meniscal root tear
• Activity modification should recommended e.g. no running / jumping but can FWB as pain
allows

SYMPTOMS SUGGESTIVE OF EXTENSOR MECHANISM DISRUPTION2

• Trauma
• Inability to weight bear
• Pain
• Inability to extend knee

SYMPTOMS SUGGESTIVE OF ACUTE LOCKED KNEE2

• Trauma
• Pain
• Difficulty weight bearing
• Inability to extend knee

Injury INFECTION
• Red hot and swollen joint
• Possible penetrative trauma
• Prosthetic joint
SEE HOT SWOLLEN JOINT PATHWAY
IF CONCERNED REFER TO ACCIDENT AND EMERGENCY

2
Map of Medicine – Alarming features Knee assessment 2010
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RED FLAG SCREENING: SPECIFIC FOR KNEE PATHOLOGY
Injury TUMOUR
• Lump or bony mass of unknown origin
• Assess for bony or soft tissue masses
• Differential diagnosis to consider: Paget’s disease, cold bone lesion (tuberculosis), benign
soft tissue lump (lipoma), benign bone tumour
REFER TO 2 WEEK PATHWAY FOR SUSPECTED CANCER - ORTHOPAEDICS

ACUTE INJURY - FRACTURE OR DISLOCATION

• Deformity
• Bony tenderness
• Inability to weight bear (see Ottawa rules)
• Neurovascular examination is essential
• Deformity and severe pain in any patient known to have metabolic bone disease - highly
suspicious of pathological fracture
REFER TO ACCIDENT AND EMERGENCY

ACUTE INJURY - EXTENSOR MECHANISM DISRUPTION

• Inability to weight bear
• Swelling
• Deformity
• Neurovascular examination is essential
• Palpable gap in extensor mechanism
• Inability to straight leg raise (SLR)

Quadriceps or patellar tendon rupture

• Quadriceps tendon rupture occurs mostly in people older than 45 years of age, whereas
patellar tendon rupture occurs mostly in people younger than 45 years of age
• More common in men
Symptoms:
• Usually occurs during sporting activity or after a fall, but can also occur spontaneously owing
to underlying disease
• Sudden onset of anterior knee pain / giving way
Signs:
• Inability to straight leg raise or extend the knee
• Change in height / position of the patella
• A palpable gap in the patellar or quadriceps tendon (although this may be difficult to detect
owing to overlying haematoma)
REFER TO ACCIDENT AND EMERGENCY

ACUTE INJURY - ACUTE LOCKED KNEE

• Joint line tenderness
• Possible effused knee
• Inability to straighten knee fully (true block to knee extension)
• If after trauma and clinical diagnosis clear
REFER TO ACCIDENT AND EMERGENCY

DVT
• Pain and swelling in one leg (both legs may be affected)
• Tenderness and changes to skin colour / temperature with vein distension
• May use 2-level DVT Wells score (link)
REFER TO ACCIDENT AND EMERGENCY
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RED FLAG SCREENING: SPECIFIC FOR KNEE PATHOLOGY
Injury SEPTIC BURSITIS
• The bursa is not only inflamed but also infected
• Unlike most cases of aseptic bursitis, septic bursitis is a potentially serious medical condition
and prompt medical attention is advisable
• An estimated 20% of bursitis cases are septic
• A bursa may become infected if an infectious bacterium enters the bursa through a cut,
scrape, puncture, bug bite or other means
• It is possible to have septic bursitis without an obvious entry point on the skin
• Certain conditions and medications suppress people’s immune systems or affect circulation,
making them more susceptible to developing septic bursitis e.g. people with cancer, HIV/
AIDS, chronic obstructive pulmonary disease (COPD), lupus, alcoholism, or diabetes may
have compromised immune systems and be more likely to get septic bursitis
• May or may not have trauma / specific event precipitating onset of symptoms
• Local pain and/or swelling at the knee joint
• Specific indicators that the bursa may be infected such as:
• Extreme warmth and redness of the skin at the joint
• Acute tenderness of the bursa
• Fever or chills
• Joint pain
• Generally feeling sick
If there is any doubt as to whether a bursa may be infected then refer to ED for oral or
intravenous antibiotics

RHEUMATOLOGY
• Refer urgently to Rheumatology or via the EIA Pathway if an inflammatory polyarthritis is
suspected
• Refer anyone with persistent synovitis of undetermined cause to Rheumatology
Examples of signs and symptoms that may be present:
- The small joints of the hand or feet are affected
- More than one joint is affected
- There has been a delay of 3 months or longer between symptom onset and seeking
medical help

HAEMARTHROSIS
• All acute knee injuries with haemarthrosis (where the patient is not on anti-coagulants)
should be treated as a torn ACL until proven otherwise and referred to Orthopaedic Knee
Consultant
• These injuries require x-ray (AP, lateral and skyline views) and an MRI to rule out fracture
• If the patient is on anti-coagulants, please refer to the Hot Swollen Joint pathway

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DIAGNOSIS: OSTEOARTHRITIS
TYPE OF
GUIDELINES
INFORMATION
Background • Focal areas of damage to the articular cartilage
information • Remodelling of underlying bone and the formation of osteophytes; new bone at joint margins
• Mild synovitis
• Structural changes, symptoms, and disability are often discordant; for example, severe
structural changes may be present without symptoms and symptoms may be severe but not
disabling
• Osteoarthritis can be defined clinically or radiologically
• Osteoarthritis has multiple risk factors, but only a few of these are modifiable
• Knee osteoarthritis is very variable in its outcome
The natural history of symptomatic knee osteoarthritis has not been well documented, but
some people improve, some people stay much the same, and some have progressively worse
symptoms and structural changes, and eventually require joint replacement.

Subjective • Can be bilateral and symmetrical

History • Unilateral osteoarthritis of the knee is usually secondary to predisposing trauma or disease
• Pain can be localised to the affected compartment:
- Medial tibiofemoral: anteromedial pain, mainly on walking
- Lateral tibiofemoral: anterolateral pain, mainly on walking
- Patellofemoral: localized anterior knee pain that is worse on inclines or stairs, particularly
when going down; progressive aching on prolonged sitting that is relieved by standing
• Stiffness after rest is common
• ‘Giving way’ is a common complaint:
- ‘Giving way’ is related to altered patella tracking, weak quadriceps muscles (pain inhibition),
severe patellofemoral osteoarthritis, and altered load bearing mechanics
• Locking of the knee joint is a characteristic feature:
- Pseudo locking prevents the knee from being straightened
- True locking suggests that there is loose meniscal cartilage in the joint

Examination • Crepitus and tenderness along the joint line or with pressure on the patella are common
findings • Flexion and extension are usually restricted
• Weakness of the quadriceps is suggested if passive extension of the knee joint is greater
than active extension
• Small-to-moderate effusions are not uncommon
• With advanced osteoarthritis of the knee there may be:
o Bony swelling of the femoral condyles and lateral tibial plateau
o Varus deformity, or less commonly, valgus deformity
• Functional assessment of activities / movements which, the patient specifies as problematic,
for example, sit to stand, going up steps, walking
• Assess joints above and below
• Differential diagnoses:
- Inflammatory arthritis - Suspect if:
- Stiffness lasts longer than 30 minutes, pain is worse at night, or stiffness and pain are
relieved by activity
- Metacarpophalangeal (MCP), wrist, elbow, or ankle joints are involved
- Consider: Rheumatoid arthritis, Psoriatic arthritis, Ankylosing spondylitis, Gout,
Pseudogout (pyrophosphate arthropathy - may coexist with osteoarthritis, reactive arthritis,
Arthritis associated with connective tissue disorders such as systemic lupus erythematosus,
fibromyalgia, septic arthritis
- Major ligamentous injury (recent and old injuries)
- Bursitis
- Cancer

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DIAGNOSIS: OSTEOARTHRITIS
TYPE OF
GUIDELINES
INFORMATION
Investigations A working diagnosis of osteoarthritis can be made without radiological or laboratory
investigations
• If the person is 45 years of age or more and symptoms and signs clearly suggest
osteoarthritis:
- Affected joints are painful when used - the person may also have pain at rest, crepitus, or a
limited range of movement
- Affected joints become stiff after resting
- There are no obvious signs of inflammation, such as severe and prolonged morning
stiffness, a large effusion, or a hot joint
• Structural changes (found on examination or shown by radiological imaging) often correlate
poorly with symptoms and disability
• Imaging and other special investigations are not definitely required as they do not confirm the
diagnosis or alter decision making
• MRI is only indicated if symptoms don’t correlate with clinical picture
• Imaging and special tests may be useful for excluding other conditions

Conservative • Assess the severity of pain and the effect of osteoarthritis on the individual’s function, quality
management of life, occupation, mood, relationships, and leisure activities
• Formulate an individualised management plan in partnership with the person with
osteoarthritis, taking into account:
o Comorbidities that compound the effect of osteoarthritis or the risk of adverse effects from
treatments
o The person’s expectations, needs, and anxieties
The core treatment to be offered to everyone with osteoarthritis is education, advice, and
access to information:
• Information on osteoarthritis and advice on self-management should be offered repeatedly
• Give people printed information and advise them where they can find more information about
osteoarthritis and its treatment, including self-management; for example:
- The National Institute for Health and Care Excellence (NICE) publication Osteoarthritis:
Understanding NICE guidance, www.nice.org.uk (pdf)
- Arthritis Care, 0808 800 4050, www.arthritiscare.org.uk
- Arthritis Research UK, 0870 850 5000, www.arthritisresearchuk.org
- NHS Choices, www.nhs.uk
- Arthritis and Musculoskeletal Alliance (ARMA), www.arma.uk.net
• Explain how osteoarthritis is diagnosed, and that X-rays are not always needed to make the
diagnosis
• Explain about the condition and its prognosis
• Provide individualised advice about the options for treatment
• The underlying message is that something can be done to help

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DIAGNOSIS: OSTEOARTHRITIS
TYPE OF
GUIDELINES
INFORMATION
Conservative Conservative Treatment
management
• Exercise, weight loss (if needed), paracetamol, and topical nonsteroidal anti-inflammatory
drugs (NSAIDs)
• Advise on joint protection and emphasise the importance of aerobic and strengthening
exercise (whatever the person’s age, comorbidity, level of pain, or disability) - this may
require referral to physiotherapy
• Advise on coping with restricted activities of daily living such as washing, dressing, and
toileting - this may require referral to occupational therapy
• If appropriate, advise about protective footwear, hot/cold packs, and TENS
• Provide information about the drugs (topical NSAIDs, capsaicin, paracetamol) that are used
to treat pain, and how the risk of adverse effects can be minimised
• Provide information about how to use simple analgesia to gain maximum benefit
• Start using analgesia before the pain is unbearable
• Use paracetamol regularly as prescribed, to prevent the pain becoming unbearable
Strengthening Exercise and Aerobic Fitness Training
• Referral to Physiotherapy: assessment of individuals’ goals, functional limitations and
expectations to enable plan which is meaningful to the patient and realistic for them to adhere to
• Gradual loading, strengthening, group environment e.g. OA knee class if available, pacing /
prioritising, graded return to activity, variety of lower limb and whole body exercise
• Aerobic fitness training
Orthotics / Assistive Devices
• Supports and braces for people with biomechanical joint pain or instability e.g. medial off loader
brace
• Appropriate footwear for people with lower limb osteoarthritis
• Walking aids
Weight loss
If the person is overweight or obese refer to Change Point - Everyone Health
http://www.nottshelpyourself.org.uk
Drug Treatments
• Paracetamol - regular dosing is more effective than use ‘as required’
• Topical nonsteroidal anti-inflammatory drugs (NSAIDs)
• If paracetamol and/or topical NSAIDs are ineffective:
• Oral NSAIDs
• If low-dose aspirin is being used, avoid NSAIDs if possible.
• Opioids - Codeine should be tried first, alone or together with paracetamol.
• Topical capsaicin
• Intra-articular corticosteroids

Referral on for • Before considering referral, check that the person wishes to be referred, and that they are fit
orthopaedic for surgery
opinion: • Refer if the person has symptoms that have a substantial impact on their quality of life and
are refractory to non-surgical treatment
• Refer before there is prolonged and established functional limitation or severe pain
• Refer for arthroscopic lavage and debridement only if the person has knee osteoarthritis with
a clear history of mechanical locking
• Partial, total or patella knee replacements will be considered after exhausted all other
avenues

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DIAGNOSIS: MENISCUS INJURY – ACUTE
TYPE OF
GUIDELINES
INFORMATION
Background • Medial meniscus injury 2-5 x more often than lateral
information • Posterior horn in 80% of cases
• History and joint line tenderness to palpate posterior to MCL are strong indicators of meniscal
injury
• Acute
- In young people usually meniscal injury is an associated injury, present with other
ligamentous / bony involvement
- Always suspect that the ACL has been injured, menisci are often injured during weight
bearing and twisting
- Most meniscal tears occur during sporting injuries that involve a twisting movement while
standing on a bent knee

Subjective • Traumatic onset Typically with tibial rotation whilst weight bearing with the knee in flexion
history (*ask about ability to weight bear at time of onset, consider fracture/red flags)
• May occur as result of repetitive action such as repeated squatting
• Sharp/stabbing pain, well localised on the medial or lateral joint line
• May describe:
- Locking – knee getting stuck, reduced range of extension movement
- +/- Giving way
• Swelling can occur: the volume of swelling is mild to moderate, and occurs several hours
after the injury
• Over the following weeks, there may be recurrent swelling
• A firm bulge originating from the joint line is indicative of a cyst

Examination • Joint line tenderness on palpation

findings • Loss of passive extension – blocked / hard end feel
• May have positive Meniscal tests: McMurrays / Thessaly’s / DD Scoop
• Effusion is possible
• Consider referral from other regions e.g. hip, lumbar spine, distal neurovascular assessment
may be necessary
*N.B. https://cks.nice.org.uk/knee-pain-assessment

Investigations • X-Ray to exclude fracture if suspected

• MRI to confirm if clinical uncertainty – for acute, not degenerative
• Root tear or Bucket Handle tears should be referred to Orthopaedics for repair (classed as
URGENT) *they will have mechanical symptoms

Conservative • Conservative management

management • Advice, education around condition, management of expectations especially regarding
conservative vs surgery
• Physiotherapy – load management, gradual loading, strengthening, proprioception, patient
specific / led goals, return to meaningful activity / work
• Analgesia
• Injection – to settle intraarticular inflammation and allow improved pain management &
compliancy to rehabilitation (especially if pseudo locking)
• Injection would not interfere with arthroscopic time frame

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DIAGNOSIS: MENISCUS INJURY – ACUTE
TYPE OF
GUIDELINES
INFORMATION
Referral on for • If acute and presents with true locking, refer to Secondary Care URGENT
orthopaedic • If diagnosis is unclear refer to MSK Hub for further investigation
opinion • If there is severe pain and high impact on function refer to MSK Hub
• Failure to improve with conservative management after 3-6/12
• Surgery may be offered if poor response to an injection
• May consider sooner referral for patients under 35 years of age whose occupation, livelihood
or sport is affected

DIAGNOSIS: MENISCUS – DEGENERATIVE

TYPE OF
GUIDELINES
INFORMATION
Background • Medial meniscus injury 2-5 x more often than lateral
information • Posterior horn in 80% of cases
• History and joint line tenderness to palpate posterior to MCL are strong indicators of
meniscal injury
• They can also occur in association with a degenerative process with little or no perceptible
trauma: these may be asymptomatic
• Poor vascularity results in poor healing
40% of 40+ year olds will have a degenerative meniscus
50% of 50+ year olds will have a degenerative meniscus
60% of 60+ year olds will have a degenerative meniscus

Subjective • Degenerative in nature – may be insidious or identifiable onset

history • May occur as result of repetitive action such as repeated squatting
• Sharp/stabbing pain, well localised on the medial or lateral joint line
• May describe:
- Locking – knee getting stuck, reduced range of extension movement
- Giving way
• Swelling usually occurs: the volume of swelling is mild to moderate, and occurs several
hours after the injury.
• Recurrent swelling may occur with activity

Examination • Joint line tenderness on palpation especially behind MCL

findings • Loss of passive extension
• May have positive Meniscal tests: painful joint line palpation, possibly positive McMurrays /
Thessaly’s / DD Scoop
• There may be an effusion
• Consider referral from other regions e.g. hip, lumbar spine, distal neurovascular assessment
may be necessary

Investigations • X-ray to exclude fracture if suspected

• MRI not required unless X-Ray findings do not match symptoms

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 DIAGNOSIS: MENISCUS – DEGENERATIVE
TYPE OF
GUIDELINES
INFORMATION
Conservative DEGENERATIVE MENISCAL TEARS3
management
Over the long term, patients who undergo knee arthroscopy versus those who receive
conservative management strategies do not have important benefits in pain or function4
• A systematic review of 13 RCTs and 12 observational studies showed
- With respect to pain, the review identified high-certainty evidence that knee arthroscopy
results in a very small reduction in pain up to 3 months and very small or no pain reduction
up to 2 years when compared with conservative management.
- With respect to function, the review identified moderate-certainty evidence that knee
arthroscopy results in a very small improvement in the short term and very small or no
improved function up to 2 years.
- Patients with true locking (unable to fully extend their knee) may still benefit from
arthroscopy5
Conservative management
- Advice, education around condition, management of expectations especially regarding
conservative vs surgery
- Physiotherapy – load management, gradual loading, strengthening, proprioception, patient
led goals, return to meaningful activity/work
- Analgesia
- Injection – if not able to engage in exercise/advice due to pain

Referral on for • If diagnosis is unclear

orthopaedic • If there is severe pain and high impact on function, may consider referral without true locking
opinion • Failure to improve with conservative management after 3/12
• May consider sooner referral for patients under 35 years of age whose occupation, livelihood
or sport is affected

DIAGNOSIS: MENISCUS – LIGAMENT INJURY

TYPE OF
GUIDELINES
INFORMATION
Background ACL
information
• The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the
knee
• Injuries occur predominantly in a young and sports-active population
• Patients can be left with significant disability following injury to the ACL
• The injury leads to alteration in the mechanics of the knee
• This mechanical deficit can lead to an increased risk of meniscal injury and / or early onset
osteoarthritis
• Joint preservation is the aim
• ACL rupture with early return to sport when not ready leads to meniscal bucket handle tear

3
Map of Medicine – Meniscal tears (2010)
4
BrignardelloPetersen R et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ
Open 2017;7:e016114
5
Siemieniuk, R et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a practice guideline. The BMJ 2017;357:1982.

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 DIAGNOSIS: MENISCUS – LIGAMENT INJURY
TYPE OF
GUIDELINES
INFORMATION
Subjective • Injury at onset of symptoms traumatic in nature
history - Typically of decelerating nature or change in direction on a fixed foot, hyperextension
- A popping sensation, or a sensation that the knee ‘came apart’, or dislocated at the time of
the injury
- Common in skiing due to knee position and impact/twisting injuries
- Significant swelling within a few hours of the injury6 7
• Main complaints:
- Instability of the knee – ‘giving way/buckling’
- Description of knee ‘not feeling right’
- Compromised quality of life
- Early development of a large haemarthrosis often suggests ACL injury6

Examination • Swelling
findings • Palpation for joint line tenderness
• Assess all ligament integrity – valgus stress, Varus stress, Lachman’s, Pivot Shift, posterior
drawer test, recurvatum test, dial test, ER recurvatum test6
• The Lachman test is often positive, but its accuracy and utility in primary care settings is not
known
• An anterior drawer test may be positive6 7
• Dial test – positive with more than 10 degrees difference side to side
N.B guarding due to pain can give false negatives

Investigations • X-Ray – AP, lateral and skyline views to rule out fracture
• MRI - early MRI is indicated

Conservative ACL injury with MCL injury requires brace (0-90 degrees for 6/52 FWB)
management
*Currently available at KMH and Newark MSK Hub sites*
If patient has not been seen at fracture / soft tissue clinic a referral to secondary care is
indicated
Consider need for surgery when:
• Instability with ADLs
• High severity of disability
• Failure of conservative treatment
• Based on patients age/sporting level and disability
Conservative Management
• PRICE
• Analgesia
• Physiotherapy to commence functional rehabilitation
- Functional strengthening
- Psychological confidence improving treatment
- Proprioception treatment
- Achieve FROM
- Avoid electrotherapy
- Protocols to use available at KMH and Newark hub sites
- Info and Prehab classes currently available at KMH and Newark Physiotherapy
departments

6
Map of Medicine : Knee ligament tears (2010)
7
Clinical Knowledge Summaries : Knee pain assessment

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DIAGNOSIS: MENISCUS – LIGAMENT INJURY
TYPE OF
GUIDELINES
INFORMATION
Conservative Surgical Management
management
• There is variation in technique across the UK
- Autograft – most common and used most frequently include: bone-tendon-bone (patellar
tendon) or 4 strand hamstrings
- Allograft
- Synthetic ligaments
• Aim / indication: to restore functional stability to the knee without compromising other aspects
of the knee including ROM
• Knee should be ‘quiet’ at operative time – settled post-injury inflammatory response with full
ROM
• Age and degenerative change are not contraindications to surgery

Referral on for • Early stabilisation of ACL reduces incidence of meniscal pathology with return to sport too
orthopaedic soon
opinion • Consider referral to the MSK Hub / Orthopaedics in Secondary Care if grossly unstable or
not responding to conservative measures

Background LCL / POSTERO-LATERAL CORNER (PLC)

information
• PLC injuries are always combined with other injury in the knee
• Lateral collateral ligament injury
- A lateral collateral ligament injury is less common than a medial collateral ligament injury
- Injury to the lateral collateral ligament can occur in combination with other posterolateral
complex structures including the peroneal nerve due to their proximity
- The lateral collateral ligament is a strong connection between the lateral epicondyle of the
femur and the head of the fibula
- Its function is to resist Varus stress on the knee and tibial external rotation and is thus a
stabiliser of the knee
- When the knee is flexed to more than 30°, the LCL is loose. The ligament is strained when
the knee is in extension

Subjective • Symptoms:
history - The mechanism of injury may be a direct blow to the medial aspect of the knee, or other
Varus stress.
- There is usually acute onset of lateral knee pain and cessation of activities
• Grading of injury:
- Grade 1
- Mild tenderness and minor pain over the lateral collateral ligament
- Usually no swelling
- The Varus test in 30° is painful but doesn’t show any laxity (< 5 mm laxity)
- Grade 2
- Significant tenderness and pain on the lateral collateral ligament and on medial side of the
knee
- Swelling in the area of the ligament
- The varus test is painful and there is laxity in the joint with a clear endpoint. (5 -10mm
laxity)
- Grade 3
- The pain can vary and can be less than in grade II
- Tenderness and pain at the medial side of the knee and at the injury
- The Varus test shows a significant joint laxity (>10mm laxity)
- The feeling of having a very unstable knee
- Swelling

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 DIAGNOSIS: MENISCUS – LIGAMENT INJURY
TYPE OF
GUIDELINES
INFORMATION
Examination • Tenderness over the lateral collateral ligament (at the lateral joint line)
findings • Instability or pain on Varus stress test
• ‘Pop’ heard or felt in the knee at time of injury - this can be symptomatic of root meniscal
injury which requires early MRI scan
• May have swelling, bruising, stiffness, erythema or deformity of the knee
• Neurological examination if signs of peroneal nerve involvement
• Increased rotation of the tibia

Investigations • X-Ray to rule out fracture

• MRI – investigate detail of injury to LCL / PLC
Conservative • If LCL tear with PLC is suspected urgent MRI is required
management • Referral should be made to Secondary Care Orthopaedics for assessment
Referral on for • Referral on for Orthopaedic opinion
orthopaedic • Surgical management t be determined in secondary care
opinion
Background MCL
information
• The medial collateral ligament is one of the most commonly injured ligaments of the knee
• It is the primary biomechanical restraint to valgus laxity against valgus stress at 0° - 30° of
knee flexion
• MCL injury often occurs when an acute valgus load is applied and may occur in isolation or
involve multiple ligaments
• As the severity of the injury increases, so does the likelihood of injury to other associated
ligamentous and meniscal structures

Subjective • Most injuries result from a valgus force on the knee from direct contact or with cutting
history manoeuvres when an athlete plants their foot and then forcefully shifts directions
• The location of swelling is a clue to the extent of injury
- Isolated MCL injuries often present as localised soft tissue swelling
- Whereas combined ACL/PCL tears result in significant hemarthrosis and generalised knee
effusion
Examination • To assess MCL laxity the patient should be relaxed and the contralateral leg is used as a
findings control for any medial joint line opening.
• A gentle valgus force should be applied to the leg with the knee in 30 degrees of flexion
thereby isolating the MCL
- If lax in 30 degrees knee flexion = conservative treatment
- If lax in full extension refer to Orthopaedics as this suggests a multi-ligament injury
• MCL injuries can be graded 1-3; assessed by a valgus force in 30 degrees flexion:
- Grade 1 – 1 to 5mm laxity
- Grade 2 - 6 to 10mm laxity
- Grade 3 >10mm laxity
(compared to the other knee)
• In general, an isolated MCL tear leads to valgus laxity in flexion, while additional injury to the
secondary valgus restraints (PCL or ACL) leads to increased laxity in extension.
• High-energy injuries resulting in MCL injury frequently damage other knee ligaments in
conjunction with the MCL:
- 78% of grade 3 MCL sprains will include injury to an associated structure
- Approximately 95% of these concomitant MCL injuries involve the anterior cruciate ligament
(ACL)8
8
Grant JA, Tannenbaum E, Miller BS, Bedi A. Treatment of combined complete tears of the anterior
cruciate and medial collateral ligaments. Arthroscopy. ⊲ Home Page ⊲ Next Page ⊲ Previous Page
 DIAGNOSIS: MENISCUS – LIGAMENT INJURY
TYPE OF
GUIDELINES
INFORMATION
Investigations • X-Ray
- Weight bearing AP, lateral and sky line views
- Bony avulsions or chondral fragments may be present
- Lateral tibial plateau fractures can also result from valgus stress to the knee and may mimic
valgus instability on examination
• MRI
- Useful to assess the location, grade, and other concomitant injuries to the knee such as
ACL tear or medial meniscus tear

Conservative • Acute isolated MCL injuries are treated non-operatively unless bony avulsion, tibial plateau
management fracture or chondral fragments are present
• PRICE
• Weight bearing as pain allows (with hinged knee brace if needed)
- AROM, concomitant strengthening exercises, proprioception
- Return to activity within: Grade 1: 3/52; Grade 2: 6/52; Grade 3: 9/52
• Combined acute MCL and ACL injuries – treatment via MSK Hub / Secondary Care
• Consider Electrotherapy treatment (US) with patients not responding to exercise
• Consider MCL Steroid injection for pain relief

Referral on for • Surgical management is not indicated unless part of the unhappy tirade
orthopaedic
opinion

Background PCL
information
• The PCL is the major stabilising ligament of the knee and prevents the tibia from moving
backwards too far
• It is twice as thick as the ACL and therefore less commonly injured
• Its primary function is resisting the posterior displacement of the tibia in relation to the femur
• Its secondary function is preventing hyperextension and limiting Varus or Valgus rotation

Subjective • The most common mechanisms of PCL injuries include pretibial trauma, hyperflexion, and
history hyperextension of the knee.
• In most of the PCL injuries caused by hyperflexion, the posteromedial bundle remains intact
and only the anterolateral bundle is ruptured9
• PCL tears can occur in isolation but are mostly in combination with other injuries
• The PCL can also be torn in a car accident where a posterior force is applied to the tibia
when the knee in a flexed position hits the dashboard
• If only the PCL is injured (in the absence of injury to the posterolateral complex), the person
may be relatively asymptomatic immediately after the injury with little pain and swelling
• There may be posterior pain (or pain on kneeling), although the person may complain of
anterior pain with a chronic PCL injury

Examination • A careful vascular examination of the lower extremities is essential because a PCL injury can
findings be accompanied by a popliteal artery injury
• If the pulses are weak or the ankle-brachial index is ≤0.8, an intimal tear should be
suspected, and arteriography should be performed
• If blood flow disruption below the knee is obvious, arteriography should be omitted to prevent
delay in treatment
• Acute PCL injuries present with joint swelling and about 10° to 20° of restriction in further
flexion due to pain
• Chronic PCL injuries may present with limited activity such as having difficulty in climbing
slopes due to lethargy and pain in the anterior and medial areas of the knee rather than
instability
9
Lee BK, Nam SW. Rupture of Posterior Cruciate Ligament: Diagnosis and Treatment Principles. ⊲ Home Page ⊲ Next Page ⊲ Previous Page
Knee Surgery and Related Research. 2011 Sep;23(3):135-141
 DIAGNOSIS: MENISCUS – LIGAMENT INJURY
TYPE OF
GUIDELINES
INFORMATION
Examination • The posterior drawer test is the most accurate test for PCL injuries: at 90° of knee flexion,
findings posterior sagging of the tibia is observed on the affected side (severe swelling can give you
a false negative)
• The posterior drawer test will often be positive, and the posterior sag test may be positive
• Posterior drawer test, dial test, Varus and Valgus test should be done especially if the patient
complains of severe posterior knee pain in >90° of flexion
• The dial test, posterolateral drawer test, external rotation recurvatum test, and reverse pivot
shift test can also be used to assess injuries to the posterolateral structures
• A positive external rotation recurvatum test is more indicative of an ACL injury than a PCL
injury and the reverse pivot shift test should be used with care because the test may yield
positive results in about 30% of normal knees

Investigations • X ray
- The presence of a fracture can be determined on the anteroposterior, lateral, and skyline
views of the knee
- The lower limb alignment, especially the presence of Varus malalignment, can be evaluated
on the standing radiographs
• MRI
- To assess for associated ligament injuries.
- Bone bruise patterns on MRI can be helpful in identifying the mechanism of injury. In acute
PCL injuries, bone bruises are often located anterior to the tibia. In chronic PCL injuries
MRI scans may appear to be normal if the ligament healed spontaneously.

Conservative • To be determined in secondary care

management • Conservative treatment is indicated for PCL injuries with 5 to 10 mm posterior instability
(grade I and II)
• Surgical treatment is recommended for PCL injuries with ≥10 mm posterior instability (grade
III) or with combined collateral ligament injuries or avulsion fractures

Referral on for • If PCL tear is suspected, referral should be made to secondary care Orthopaedics for
orthopaedic assessment and consideration of PLC involvement
opinion

DIAGNOSIS: CHONDRAL INJURY / DEFECTS

TYPE OF
GUIDELINES
INFORMATION
Background Chondral Defect
information
A detachment of bone or cartilage most commonly in the femoral condyle. Symptoms are
related to softening of the cartilage rather than hardening as in OA.
• Hyaline articular cartilage is an avascular structure, which results in poor healing; it is not
innervated
• Varies in thickness; the cartilage on the articular surface of the patella can reach a thickness
of up to 7-8mm
• A large retrospective study10 analysed a large database of arthroscopies (25.124
arthroscopies performed from 1989 to 2004)
- Chondral lesions were found in 60% of patients. They were classified as localised focal
osteochondral or chondral lesions (67%), osteoarthritis (29%), osteochondritis dissecans
(2%) and other types in 1%
- The most common associated articular lesions were meniscus tear (37%) and injury of the
ACL (36%)
10
Widuchowski W. et al., Articular cartilage defects: Study of 25.124 knee arthroscopies, ScienceDirect, ⊲ Home Page ⊲ Next Page ⊲ Previous Page
The Knee 14 (2007) 177-182
DIAGNOSIS: CHONDRAL INJURY / DEFECTS
TYPE OF
GUIDELINES
INFORMATION
Background - The analysis of the onset of symptoms revealed that in 58% it was a traumatic non-contact
information onset, usually connected with a day living activity (45%) and with sports participation (46%,
especially football and skiing)
Osteochondritis Dissecans
A relatively common, idiopathic condition where crack form in the articular cartilage affecting
the subchondral bone.
• Most commonly occurs in people 13–21 years of age, but can affect younger children and
adults
• The condition is usually unilateral, but can affect both knees (can affect other joints)

Subjective Chondral Defect

history
• Can range from asymptomatic to severely limiting pain
• There may be a history of ligament injury (often the ACL), patellar dislocation, or a traumatic
“dashboard” injury to the knee
• Pain increases on physical activity
• Intermittent swelling, related to activity in more chronic cases
• Pain with prolonged sitting, stair climbing, and kneeling may localise the pain to the patella or
femoral trochlea
Osteochondritis Dissecans
• Symptoms will initially be vague, poorly-localised knee pain, which may be aggravated by
activity
• There may also be morning stiffness and recurrent swelling
• They may describe locking, catching, or giving way; these symptoms suggest that a loose
body is present

Examination Chondral Defect

findings
• Haemarthrosis are seen in almost all acute injuries that create a full thickness chondral injury
• May exhibit symptoms to suggest loose body – loss of end range movement and locking
Osteochondritis Dissecans
• There may be quadriceps weakness and atrophied, focal bony tenderness, a small knee
effusion and limitation of knee extension
• Wilson’s test may be positive: with the knee flexed to 90 degrees and the tibia rotated
medially (internally), the person is asked to extend the knee against resistance
• The test is considered positive if pain occurs at approximately 30 degrees of flexion; pain is
usually relieved when the tibia is released from medial (internal) rotation

Investigations Chondral Defect

Staging on MRI / X-Ray as below:
• Stage I MRI Subchondral oedema
Stage I X-Ray None
• Stage II MRI Associated subchondral fracture without detachment
Stage II X-Ray Osteopenic Area
• Stage III MRI Detached non-displaced fragment + joint effusion
Stage III X-Ray Slight lucency + possible loose body
• Stage IV MRI Osteochondral Fragment displaced + joint effusion
Stage IV X-Ray Increased lucency + loose body
• Stage V MRI Subchondral cyst formation + degenerative changes
Stage V X-Ray Secondary degenerative change

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 DIAGNOSIS: CHONDRAL INJURY / DEFECTS
TYPE OF
GUIDELINES
INFORMATION
Investigations Osteochondritis Dissecans
X-Rays
• Offer X-rays of both knees
• Ensure that the X-ray request form states that osteochondritis dissecans is suspected
• There may be no abnormality detected, or the X-rays may show a radiolucent lesion or a
loose body and indicated the need for MRI
Conservative • Advice, education around condition, management of expectations especially regarding
management conservative vs surgery
• Physiotherapy – load management, gradual loading, strengthening, proprioception, patient
led goals, return to meaningful activity/work
• Analgesia
• Injection – if not able to engage in exercise/advice due to pain
Referral on for ALL OSTEOCHONDRAL DEFECTS SHOULD BE REFERRED TO SECONDARY CARE
orthopaedic
• Refer on if true locking
opinion
• Surgical interventions offered locally are chondroplasty, microfracture11, osteochondral
autographs, allographs and primary repair if a large defect
• Out of area - Implantation (ACI) may be offered for patients – to be referred by Orthopaedic
surgeon.
Osteochondritis Dissecans
If suspected on the basis of clinical or radiographic features, refer to an orthopaedic surgeon or
other musculoskeletal specialist for confirmation of the diagnosis (for example by MRI) and for
treatment planning (surgery may be required if conservative measures fail)
11
Cochrane Surgical interventions (microfracture, drilling, mosaicplasty, and allograft transplantation) for treating isolated cartilage defects of the knee in adults 2016.

DIAGNOSIS: PATELLOFEMORAL PAIN SYNDROME PFPS / ANTERIOR KNEE PAIN AKP

TYPE OF
GUIDELINES
INFORMATION
Background Patellofemoral Pain Syndrome
information
• Patellofemoral pain is a diagnosis of exclusion
- Exclude any red flags for more serious pathology
- Consider other causes of anterior knee pain
• Synonyms for patellofemoral pain syndrome are ‘anterior knee pain syndrome’, ‘patellar
dysfunction’, ‘chondromalacia patellae’ or ‘chondropathy’
• Factors that have recently been described as associated with PFPS are
- a lower knee extension strength, a lower hip extension strength and decreased flexibility of
the lower extremity muscles
- contribution of patellofemoral joint mechanics and surrounding tissues to patellofemoral pain
- contribution of foot and ankle mechanics
- contribution of hip, pelvis and trunk mechanics
• However, the aetiology of the condition is still unclear, as is the origin of the pain12
May be associated with Infrapatellar fat pad impingement/Hoffa’s fat pad:
• Intracapsular, extra synovial structure that fills the anterior knee compartment, and is richly
vascularized and innervated
• Injury to the fat pad is often caused where it becomes pinched (impinged) between the
patella and distal femur
• Can be result of knee trauma / direct trauma to fat pad
• Can develop gradually, usually caused by repeated hyperextension of the knee
12
Cochrane - Exercise Therapy for patellofemoral pain syndrome 2015 ⊲ Home Page ⊲ Next Page ⊲ Previous Page
 DIAGNOSIS: PATELLOFEMORAL PAIN SYNDROME PFPS / ANTERIOR KNEE PAIN AKP
TYPE OF
GUIDELINES
INFORMATION
Subjective Patellofemoral Pain Syndrome
history
• Anterior or anteromedial pain that is:
- Dull and aching
- Gradual in onset
- Aggravated by ascending or (particularly) descending stairs, rising after squatting or
sitting for prolonged periods (especially with the knees flexed), or sporting activities
(especially running or jumping)
- Associated with a sensation of giving way. This is not true instability, which occurs in
meniscal or ligamentous injury, when the person describes instability occurring on pivoting
or twisting; in patellofemoral pain, the sensation of giving way occurs whilst ascending or
descending stairs or when walking on an incline
• Other features in the history:
- The pain is commonly bilateral, but may affect the dominant knee more than the non-
dominant knee
- The pain may be associated with mild swelling, crepitus, snapping, or clicking, but these
features are not specific to patellofemoral pain
Infrapatellar Fat Pad Impingement
• Ache/burning at inferior pole of patella
• Pain worsens on activity
• Pain may be aggravated in knee extension

Examination Patellofemoral Pain Syndrome

findings
• There are no features specific to patellofemoral pain
• There may be no abnormal findings, or there may be a mild effusion, tenderness over medial
or lateral peri-patellar regions, crepitus and anterior knee pain on active or passive
movements
• Pain on patellar glide (movement of the patella medially and laterally with the knee slightly
flexed)
• Tests for patellar maltracking and patellofemoral alignment, and measurement of the
quadriceps (Q) angle are of limited value for diagnosing patellofemoral pain
Infrapatellar Fat Pad Impingement
• May be tender to palpate at inferior patella/over patella tendon
• Swelling may be present
• May have loss of terminal extension
• Pain with direct pressure on the medial or lateral side of the patella with the knee extended
• Pain can often be reproduced with manoeuvres designed to produce impingement

Investigations Patellofemoral Pain Syndrome

• X-Ray can be used to rule out other conditions
• Relevant investigation for clinical suspicion of other diagnosis as per guidelines
• Poor reliability or correlation between X ray/MRI findings of knees with PSFS and symptoms)13
Infrapatellar Fat Pad Impingement
• X-Ray can be used to rule out other conditions
• MRI to measure patella height Tibial Tubercle – Trochlea Grove (TT-TG) and assess articular
cartilage
13
Cochrane – Exercise therapy for patellofemoral pain syndrome 2003

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 DIAGNOSIS: PATELLOFEMORAL PAIN SYNDROME PFPS / ANTERIOR KNEE PAIN AKP
TYPE OF
GUIDELINES
INFORMATION
Conservative Patellofemoral Pain Syndrome
management
• Self-help information arthritisresearchukPFPS
• GP for advice on pharmacological treatment
• Refer to Physiotherapy:
- Advice/education
- Exercise therapy – Systematic review concluded that people with PFPS have lower knee
extension strength, lower hip extension strength and decreased flexibility of the lower
extremity muscles compared with people without PFPS14.
- Exercise programmes that comprise static and dynamic muscular exercises for both
quadriceps and hip muscles aim to improve the strength of these muscles and
consequently reduce pain by decreasing the load on the patellofemoral joint and improve
function by normalising the kinematics
- Proprioception
- Return to usual level of activities
• Electrotherapy – ultrasound not beneficial15
• Steroid Injection if unable to engage in exercise/advice due to pain
Infrapatellar Fat Pad Impingement
• Physiotherapy
- Taping can be used to unload an inflamed IFP
- Closed chain quadriceps exercises can improve lower limb control and patellar congruence
- Training of the gluteus medius and stretching the anterior hip may help to decrease internal
rotation of the hip and valgus force at the knee
- Gait training and avoiding hyperextension can also be used for long-term management

Referral on for Patellofemoral Pain Syndrome

orthopaedic
• Any red flags
opinion
• Non-progression of symptoms after 3-6/12 of conservative management
• Severe level of pain or function impairment, not managed in primary care
Infrapatellar Fat Pad Impingement
• If no progression or improvement after 3-6/12 rehabilitation
• Diagnostic uncertainty
• Worsening symptoms
• In recalcitrant cases, patients can be surgically treated with arthroscopic fat pad resection
14
Lankhorst NE et al Factors associated with patellofemoral pain syndrome: a systematic review. British Journal of Sports Medicine 2012;42(2):81-94.
15
Cochrane – Therapeutic Ultrasound for patellofemoral pain syndrome 2009

DIAGNOSIS: PATELLA DISLOCATION (ACUTE) / SUBLUXATION (SUB-ACUTE)

TYPE OF
GUIDELINES
INFORMATION
Background • Patellar instability is a term used to encompass disorders in which the patella subluxes or
information dislocates from its normal position
- Patella subluxation or dislocation may occur during sporting activities, or during activities
of daily living, in people who are at risk - usually teenage girls (for example due to joint
hypermobility syndrome)
- The patella usually relocates spontaneously
- Recurrent dislocations without traumatic cause may be associated to anomalies of
the patellofemoral joint including trochlear dysplasia, patella alta, lateralisation of the tibial
tuberosity

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 DIAGNOSIS: PATELLA DISLOCATION (ACUTE) / SUBLUXATION (SUB-ACUTE)
TYPE OF
GUIDELINES
INFORMATION
Background - Important secondary factors contributing to patellofemoral instability are femorotibial
information malrotation, genu recurvatum (hyperextended knee), and ligamentous laxity caused by
Ehlers-Danlos syndrome, and Marfan syndrome16.

Subjective Patella dislocation

history
- Leading mechanism of an acute dislocation of the patella is knee flexion with internal
rotation on a planted foot with a valgus component
- A common finding related to acute, primary, traumatic patellar dislocations is hemarthrosis
of the knee, caused by rupture of the medial ligamentous stabilisers of the patella
• Patellar subluxation
- The main symptom is recurrent episodes of the knee giving way
- The person may also complain of anterior knee pain, locking, catching sensations, and
recurrent mild swelling
- Pain can be aggravated by activities such as up and down the stairs, sports such as
running, hopping and jumping, and changing direction

Examination • Patellar dislocation

findings
- If there is moderate or severe swelling, refer to the accident and emergency department to
exclude an associated fracture
• Patellar subluxation
- There may be a small joint effusion
- Signs may be similar to those seen in patellofemoral pain
- Several clinical tests have been suggested, but their diagnostic accuracy is unclear
• Assessment
- Lower limb alignment in coronal, sagittal and axial planes
- Evidence of joint hyper laxity: measured by the Beighton hypermobility score
- Measurement of the Q-angle: an increase in Q-angle results in an increased valgus vector:
this is associated with an increased risk of instability, due to more laterally orientated forces
- Palpation of the patella: may reveal a palpable defect at the medial patellar margin and
tenderness along the course or at the insertion of the MPFL
- Patellar-glide test: A medial / lateral displacement of the patella greater than or equal to 3
quadrants, with this test, is consistent with incompetent lateral / medial restraints
- Lateral patellar instability is more frequent than medial instability
- Fairbanks patellar apprehension test: the test is positive when there is pain and defensive
muscle guarding when the patella is passively moved laterally in 20°–30° of knee flexion; a
positive test indicates lateral patellar instability. 100% sensitivity, 88.4% specificity, and
overall accuracy of 94.1%

Investigations • X-ray to rule out fracture (with true dislocation, not subluxation)
• MRI – only if recurrent event

Conservative IF FIRST TIME OR RECURRENT DISLOCATION, REFER TO ORTHOPAEDICS.

management
No immobilisation – hinge knee brace within restricted range for 6/52 then commence
movement.
• The aim of rehabilitation is to restore knee range of motion and improve patellar stability by
reinforcing the quadriceps
• Patellar subluxation – refer to Physiotherapy: strengthening, quadriceps, proprioception,
patient led goals, return to previous activities/sport
• 3-6/12 of rehab then refer to Orthopaedics if still problematic

16
Diederichs G, Issever A, Scheffler S. MR Imaging of Patellar Instability: Injury Patterns ⊲ Home Page ⊲ Next Page ⊲ Previous Page
and Assessment of Risk Factors. RadioGraphics. 2010;30(4):961-981.
 DIAGNOSIS: PATELLA DISLOCATION (ACUTE) / SUBLUXATION (SUB-ACUTE)
TYPE OF
GUIDELINES
INFORMATION
Referral on for • Refer a person to an orthopaedic surgeon if patellar dislocation occurs in a person with
orthopaedic recurrent dislocation (>3), and is associated with moderate or severe swelling, regardless of
opinion timeframe of dislocations
• If first-time traumatic patellar dislocation suspected - this recommendation is pragmatic
as investigations to assess for internal injury such as fracture, and initial immobilisation are
generally recommended10
• If patellar dislocation has not reduced spontaneously, reduction in an emergency department
is recommended

DIAGNOSIS: ITB SYNDROME

TYPE OF
GUIDELINES
INFORMATION
Background • Non-traumatic overuse injury
information • Extends from iliac crest down the lateral thigh to connect to Gerdy’s tubercle at the lateral
knee,
• Also incorporates a lateral patella attachment
• Debate over whether there is friction involved at the lateral knee between the ITB and
femoral condyle, particularly at 20-30 degrees of knee flexion or of it is irritation of a highly
innervated layer of fat that lies between the ITB and femoral condyle
• Possible non-modifiable causes – prominence of lateral epicondyles and leg length
difference
• Possible other modifiable causes – reduced flexibility, muscle weakness particularly of hip
abductors, biomechanical alterations – hip adduction, knee internal rotation and foot position

Subjective • Load, stress and frequency of load must be considered when looking at cause of symptom
history onset
• New activity may coincide with symptoms onset
• Repetitive activities involving knee flexion-extension are usually reported
• Burning pain at the level of (or just underneath) the lateral femoral epicondyle
• Sharp pain on the outer aspect of the knee that can radiate into the outer thigh or calf

Examination • Ober’s test / Modified Ober’s test

findings • Noble compression test

Investigations • Not indicated unless diagnosis unclear

Conservative • Rest, ice – initially to settle symptoms
management • Look at changes in activity/exercise – address how to incorporate change at a rate which
doesn’t cause symptoms, patient advice/education
• Adaptations for future training/activity planning
• Address muscle weakness – glutes and quads
• Address muscle stiffness – TFL, hip flexors, quads
• Proprioception / movement control
• Biomechanics
• Look at running style if appropriate– narrow step width may be a factor in increasing ITB
strain, also increasing step rate with a proportional decrease in step length assuming a
constant speed.
Study findings (Heiderscheit et al 2011) indicate that a substantial reduction in loading occurs at
the hip and knee when step rate is increased to 10% above preferred with a constant running
speed, while a 5% increase appears to reduce the total work performed by the knee.
10
Rhee S, Pavlou G, Oakley J, Barlow D, Haddad F. Modern management of patellar instability. ⊲ Home Page ⊲ Next Page ⊲ Previous Page
International Orthopaedics. 2012;36(12):2447-2456
 DIAGNOSIS: ITB SYNDROME
TYPE OF
GUIDELINES
INFORMATION
Referral on for • If diagnosis unclear, symptoms not responding to conservative management within 6/12 or if
orthopaedic symptoms are severely affecting quality of life
opinion • Injection – if not able to engage in exercise / advice due to pain
References
Is iliotibial band syndrome really a friction syndrome? Fairclough J et al. April 2007Volume 10,
Issue 2, Pages 74–76
Aderem and Louw Biomechanical risk factors associated with iliotibial band syndrome in
runners: a systematic review. BMC Musculoskeletal Disorders (2015) 16:356 DOI 10.1186/
s12891-015-0808-7
Effects of Step Rate Manipulation on Joint Mechanics during Running. Bryan C. Heiderscheit et
al. Med Sci Sports Exerc. 2011 Feb; 43(2): 296–302.

DIAGNOSIS: BAKER’S CYST

TYPE OF
GUIDELINES
INFORMATION
Background • A Baker’s cyst17 (also known as a popliteal cyst) is not a true cyst but a distension of the
information gastrocnemius-semimembranosus bursa behind the knee
• Baker’s cysts are usually secondary to:
- Osteoarthritis or inflammatory arthropathies such as rheumatoid arthritis
- Meniscal tears
- Anterior cruciate ligament damage
• Complications of Baker’s cyst include:
- Dissection or rupture.
- Consider ruptured Baker’s cyst as differential diagnosis for DVT
- Haemorrhage can occur, in particular in people taking anticoagulants
- Compartment syndrome, lower limb ischaemia, and symptoms of nerve entrapment are
also possible
- Infection - can occur spontaneously or following corticosteroid injection

Subjective • Swelling - An asymptomatic swelling behind the knee may be the only feature
history • Pain and tightness
- Non-specific posterior knee pain and a feeling of tightness
- Symptoms may be aggravated by walking (as fluid passes between the knee joint and the
cyst)

Examination • Baker’s cysts are typically found in the medial popliteal fossa
findings • Round, smooth, and fluctuant — they may be tender on palpation
• Check for signs of underlying knee pathology such as joint instability, and ligament or
meniscal damage
Investigations • X-Ray of the knee is of limited value in confirming or excluding a diagnosis of Baker’s cyst
• It may be appropriate as part of an assessment of underlying knee joint disease

Conservative • Treatment of the underlying knee joint disease often leads to regression of Baker’s cysts
management

Referral on for • May aspirate if very big - generally these are left alone
orthopaedic
opinion
17
CKS Baker’s Cyst 2016

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DIAGNOSIS: REFERRED PAIN FROM HIP / LUMBAR SPINE
TYPE OF
GUIDELINES
INFORMATION
Background • Always examine the hip in people who present with knee pain
information • Several conditions of the hip or lumbosacral spine can cause referred pain in the knee

Subjective Osteoarthritis of the hip

history
• A working diagnosis of osteoarthritis can be made without radiological or laboratory
investigations:
• Affected joints are painful when used - the person may also have pain at rest, crepitus, or a
limited range of movement
• Affected joints become stiff after resting
• There are no obvious signs of inflammatory arthritis, such as severe and prolonged morning
stiffness, a large effusion, or a hot joint
Inflammatory arthritis
• Suspect if:
- Stiffness lasts longer than 30 minutes, pain is worse at night, or stiffness and pain are
relieved by activity
- Metacarpophalangeal (MCP), wrist, elbow, or ankle joints are involved
• Consider:
- Rheumatoid arthritis
- Psoriatic arthritis
- Ankylosing spondylitis
- Gout
- Pseudogout (pyrophosphate arthropathy) - may coexist with osteoarthritis
- Reactive arthritis
- Arthritis associated with connective tissue disorders such as systemic lupus erythematosus
- Fibromyalgia
- Septic arthritis
Other issues to consider:
• Fracture of the bone adjacent to the joint
• Major ligamentous injury (recent and old injuries)
• Bursitis
• Cancer
• Lumbar radiculopathy
• Suspect sciatica if there is:
- Radicular Pain - unilateral radiating leg pain
- Low back pain - if present, it is less severe than the leg pain
- Radiculopathy - numbness / tingling (paraesthesia) / muscle weakness suggests nerve
root compression
- Positive straight leg raising test
• Examination of the hips and knees will reveal most of the conditions with symptoms similar
to sciatica
• DO NOT routinely X-ray the spine to confirm the diagnosis

Examination See individual pathways

findings
Investigations See individual pathways
Conservative See individual pathways
management
Referral on for See individual pathways
orthopaedic
opinion
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DIAGNOSIS: OTHER SOFT TISSUE
TYPE OF
GUIDELINES
INFORMATION
Background Tendon Pain
information
• Patellar tendon
• Quadriceps tendon
• 2 phases of tendinopathy continuum:
- Reactive/early disrepair – tendon response to rapid overloading e.g. increase in training,
unaccustomed activity, also direct trauma to the tendon. Tendon swells due to water
moving into the tendon matrix rather than inflammatory process. Usually reversible. Early
disrepair follows reactive tendinopathy if over loading continues.
- Late disrepair/degenerative – over loading continues, may be neuronal growth and
increase in vascularity. Progresses to degenerative tendinopathy with changes to tendon
structure, making load bearing less efficient. Tendon appears thickened and there is risk of
rupture with continued over loading.
• Lack of correlation between pain and pathology
• Psychosocial factors can play a significant part, especially fear and that tendon pain has a
significant impact on life and daily activities
• May be association between persistent tendon pain and sensitisation of the nervous system
Bursitis
Bursa are small fluid filled sacs that reduce the friction between two surfaces. They allow
muscles to move freely as they contract and relax without being subjected to too much strain or
friction.
• Prepatellar bursitis – anterior knee, inferior to patella. Also known as Housemaid’s knee
• Common problem for people who spend long periods kneeling e.g. carpet layers/roofers
• Pes Anserine bursitis – medial knee, sits between MCL and tendons of gracilis, sartorius and
semitendinosus - Pes Anserine bursitis of the knee usually develops from overuse and most
commonly affects runners
• Semimembranosus bursitis – posterior knee, sits between tendon of semimembranosus
and medial head of gastrocnemius muscle. Is intimately attached to the posterior capsule
of the knee joint and its bordering muscles. It may communicate with the knee joint by a
small opening. Also known as Baker’s cyst
• Infrapatellar Bursitis - There are two types of infrapatellar bursitis. The superficial
infrapatellar bursa sits between the skin and the patellar tendon and the deep infrapatellar
bursa sits deeper, behind patellar tendon cushioning it from the tibia behind
• Iliotibial Bursitis – Lateral knee, the iliotibial bursa sits between the iliotibial band and the
tibia, just below the knee. It is often misdiagnosed as iliotibial band syndrome
Septic Bursitis – see page 5

Subjective Tendon Pain

history • May report increase in loading such as running further/faster/uphill
• May have had trauma to tendon
• Anterior knee pain
• May be reproduced during aggravating activity or up to 24 hours afterwards
Bursitis
• Non-septic bursitis - when bursitis is caused by a trauma to the knee, swelling and other
symptoms may appear within 24 hours
• When bursitis is caused by repetitive actions such as repeated kneeling, symptoms may
appear more slowly, over several days or weeks.

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DIAGNOSIS: OTHER SOFT TISSUE
TYPE OF
GUIDELINES
INFORMATION
Examination Tendon pain
findings
• Pain on squatting, increased with increased depth of squat
• Tenderness on palpation
• Assess hip, knee and ankle/foot also
• May be evidence of central sensitisation - 3 major classification criteria;
- Evidence of pain or perceived disability that is disproportionate to the nature or extent of
the injury or pathology (this is an obligatory criterion)
- The presence of diffuse pain, allodynia and hyperalgesia (different to typically tendon pain
which is often well localised)
- Hypersensitivity of senses unrelated to the musculoskeletal system e.g. bright light, sound
smell, heat or cold
Bursitis
• Non-septic bursitis - localized swelling - An inflamed prepatellar bursa swells up with fluid,
this can be felt and seen through the skin
• As it progresses, the knee joint can look double in size. Swelling can feel soft, may appear
as obvious lump
• Pain level can vary may feel achy, may just feel tenderness with increased pressure on the
knee, for example when kneeling or just pressing down on it. Some patients with non-
infected (aseptic) knee bursitis report no tenderness or only mild tenderness
• Generally, as the swollen bursa increases in size it will become more tender and painful,
particularly if the bursa gets squeezed during extreme bending or straightening of the leg

Investigations Tendon pain

• X-Ray / MRI if traumatic onset or diagnostic uncertainty
• US – commonly show expected changes which do not correlate to symptoms
• MRI – Sagittal MRI is the most common imaging technique used to assess IFP pathology
including fibrosis, inflammation, oedema, and mass-like lesions
• Not all patients have positive imaging
Bursitis
• X-ray to rule out patella fracture if symptoms result of trauma
• Aspiration if infection is suspected
• MRI for rule out soft tissue tumour

Conservative Tendon pain

management
Reactive / early disrepair
• Manage load, tensile and compressive e.g. deep knee flexion loads and compresses
quadriceps tendon at the femoral condyle.
• Reduce load so that healing can occur
• Tendons can react during or after exercise, tendon pain can be latent – may also be felt 24
hours later
• Ibuprofen thought to inhibit proteins responsible for tendon swelling
• Isometric exercise (that does not increase compression) can reduce pain (thought to be
centrally driven, supporting theory of central sensitisation’s role) and maintain muscle
strength, may be good for early, painful stages
• Stretching - compression during stretch may aggravate a reactive tendinopathy

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DIAGNOSIS: OTHER SOFT TISSUE
TYPE OF
GUIDELINES
INFORMATION
Conservative Tendon pain
management
Late disrepair/degeneration
• Load management
• Concentric / eccentric work
• Isometric and strength exercises within tolerable ranges/reps
• Some tendon changes may be reversible but is likely to need long term management
• Injection – USGI or PRP
• Bracing not indicated
Bursitis
• Rest, ice, compression, elevation
• NSAIDs
• Aspiration
• Steroid Injection
• Physiotherapy – treat as in overuse injuries
• Manage load to allow symptoms to settle
• Introduce loading gradually
• Look at whole kinetic chain

Referral on for Tendon pain

orthopaedic
• If non-progression/no improvement after 6-12/12 rehab
opinion
• Diagnostic uncertainty
• Worsening symptoms
Bursitis
• If recalcitrant to conservative treatment
• Surgery - Bursectomy
References
Cook J, Purdam C Is compressive load a factor in the development of tendinopathy? Br J
Sports Med 2012;46:163-168.
Malliaras P, Cook J, Purdam C, Rio E. Patellar Tendinopathy: Clinical Diagnosis, Load
Management, and Advice for Challenging Case Presentations. The Journal of orthopaedic and
sports physical therapy. 2015 Sep:1-33.
Mallows A, Debenham J, Walker T, et al Association of psychological variables and outcome in
tendinopathy: a systematic review Br J Sports Med 2017;51:743-748.
Genin, J et al. Infrapatellar Fat Pad Impingement: A Systematic Review. J Knee Surg 2017;
30(07): 639-646.
Dragoo JL1, Johnson C, McConnell J. Evaluation and treatment of disorders of the infrapatellar
fat pad. Sports Med. 2012 Jan 1;42(1):51-67.
Baumbach, S.F., et al. Prepatellar and olecranon bursitis: literature review and development of
a treatment algorithm. Archives of Orthopaedic and Trauma Surgery 2014; 134: 359.
Paul Yuh Feng Lee et al. Synovial Plica Syndrome of the Knee: A Commonly Overlooked
Cause of Anterior Knee Pain. Surg J 2017; 03(01): e9-e16.

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MSK SERVICES PATHWAY - FOOT & ANKLE PATHOLOGY
GPs to follow guidance offered within this pathway and where relevant refer using
Ardens templates and within remit of CCG Restricted and Not Routinely funded policy.
Patients requiring Podiatry referral will be referred to the Podiatry SPA.

RED FLAG

• Septic arthritis • Fractures

• Dislocations • Inflammatory conditions
Diagnosis to • Tumours • Neurological lesion
monitor • Infections • Charcot foot
• Achilles tendon rupture

Medical Professionals seeing patients with

History & MSK complaints in primary care should be
Symptoms trained in assessing for alarming features and
red flags in all patients.

Injury Consider admission/urgent referral

ASSESSMENT & DIAGNOSIS OF OTHER CONDITIONS

Red Flags Plantar fasciitis

Hind/mid and forefoot OA Mortons Neuroma

Ligaments/Sprains Hallux Valgus/Rigidus

Tendinopathies/Achilles Tendon Metatarsalgia

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RED FLAG SCREENING: SPECIFIC FOR FOOT & ANKLE PATHOLOGY
Red Flags/ 1. Primary or Metastatic Tumours
sinister conditions 2. Infection or Septic Arthritis
that will alter 3. Inflammatory arthropathy
management 4. Acute ankle/foot Fracture/Dislocation
immediately 5. Achilles tendon rupture (acute)
6. Charcot foot
7. Acute drop foot
8. Soft tissue mass

History & Medical Professionals seeing patients with MSK complaints in primary care should be trained in
Symptoms assessing for alarming features and red flags in all patients.

CONSIDER ADMISSION/URGENT REFERRAL IF:

History of, or suspected malignancy investigate and refer as appropriate.
1. Symptoms suggestive of Tumours (primary or metastatic):
• PMH of cancer - Bony mets develop in 2/3 of patients with cancer - Mostly prostate, breast,
kidney
• Unexplained weight loss
• Non-mechanical night pain
• Deep, intense pain
• Pain worse at night
• Fever
• Mass presence
• Lymphadenopathy
Suspected Tumour Management: Refer urgently for specialist assessment in line with 2
week fast track cancer pathway (via Systm1 communication to GP)
2. Symptoms suggestive of Infection or Septic Arthritis:
• Risk factors for sepsis include: Comorbidities of RA, or OA, prosthetic joint, low
socioeconomic level, diabetic, alcoholism, previous intra-articular joint infection, IV use
• Constant pain
• Sudden onset, red, hot, pyrexia or red-hot joint
• High inflammatory markers
• Systemic symptoms
• Fever, not always present
Suspected Infection/Septic Arthrits Management: Refer the patient urgently to A+E with
accompanying letter.
3. Symptoms suggestive of an inflammatory condition
• Stiffness- early morning joint stiffness over 30 minutes
• Swelling-persistent swelling of one joint or more, especially if the hands joints are involved
• Squeezing the joints is painful in inflammatory arthritis
Suspected inflammatory condition management: investigate via bloods/x-ray foot
and ankle for clinical work-up and refer to Rheumatology (state in Systm1 task early
inflammatory pathway – urgent). See Rheumatology pathway for further details.
4. Symptoms suggestive of Acute ankle/foot Fracture/Dislocations:
• Trauma
• Pathological fracture (OP, Paget’s, multiple myeloma, PMH Ca)
• Neurovascular deficit
• Deformity
• Muscle wasting
• Unable/difficulties weight bearing
• Pain after a lot of training/running e.g stress fracture
• Has risk factors for osteoporosis
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RED FLAG SCREENING: SPECIFIC FOR FOOT & ANKLE PATHOLOGY
History & Suspected fracture/ dislocation management: acute fracture/dislocation should
Symptoms immediately attend A+E (with accompanying letter where possible) or fracture clinic
with urgent x-ray, depending on clinician’s clinical judgement. Suspected pathological
fractures should be referred for investigations to determine root cause via referral to
appropriate services as a matter of urgency (GP, secondary care).
If suspicion of a stress fracture where X-ray has shown no bony injury consider MRI.
5. Symptoms suggestive of Achilles tendon rupture
• Often report an audible snap or pop during sport or running activity
• Sudden, significant pain in the calf or back of the ankle - this may be described as being hit
by a racquet or kicked in the back of the leg.
o Approximately a third of people with tendon rupture do not complain of pain after the acute
pain of the rupture has eased.
• Inability to walk or continue the precipitating activity - a limp is often present.
o In some cases, the person may be able to walk as plantar flexion of the foot involves
muscles other than those related to the Achilles.
• Unable to calf raise
• Simmonds triad (angle of declination, palpation, and the calf squeeze test) to help exclude
Achilles tendon rupture:
• Positive squeeze/Thompson test- lie prone with their feet over the edge of the examination
couch. Gently and sequentially squeeze the calf muscles - in acute rupture of the Achilles
tendon the injured foot will typically remain in the neutral position when the calf is squeezed
• Palpable tendon gap- Feel for a gap in the tendon. No gap may be felt in the acute phase
(due to haematoma) or in the chronic phase (due to organization). Bruising may be seen.
• Angle of declination- Look for an abnormal angle of declination - rupture of the Achilles
tendon may lead to greater dorsiflexion of the injured ankle and foot compared to the
uninjured limb.
• Be aware that diagnosis of chronic rupture may be difficult, because:
o Pain and swelling have often subsided and the gap may have filled with fibrous tissue.
o The calf squeeze test may produce a false result.
o Calf muscles may be wasted.
o Other muscles may facilitate plantar flexion.
• Achilles tendon rupture is missed by non-specialists in about 20% of cases.
• Prompt diagnosis is important because delay in treatment can lead to poorer outcomes
including disability, more complicated surgery, and inability to return to sporting activity
Ref- https://cks.nice.org.uk/achilles-tendinopathy#!diagnosissub:1 (2016)
Management of suspected Achilles rupture: refer to A&E if acute (with accompanying
letter). These patients need to be seen as soon as possible following the rupture in case
they require surgery – typically within 2-3 days but could be seen within 6 weeks). If the
problem is beyond 6/52 post rupture, refer patient to elective orthopaedics urgently.
6. Symptoms suggestive of Charcot foot
• Dislocation of the joint
• Heat- skin feeling warmer at the point of injury
• Deep aching feeling
• Insensitivity in the foot due to neuropathy
• Instability of the joint
• Redness
• Strong pulse
• Swelling of the foot and ankle (caused by synovial fluid that leaks out of the joint capsule)
• Subluxation/deformity of the foot (misalignment of the bones that form a joint)
History of diabetes/peripheral neuropathy and the trigger for Charcot foot can be a sprain or
twisted ankle that goes unnoticed because of reduced feeling from nerve damage.

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RED FLAG SCREENING: SPECIFIC FOR FOOT & ANKLE PATHOLOGY
History & Complications of Charcot foot
Symptoms
Include calluses and ulcers, which occur when bony protrusions rub inside the shoes and may
become infected. Bone inflammation (osteomyelitis) and inflammation of the joint membranes
(septic arthritis) also may develop. Septic arthritis may manifest with malaise and fever. Blood
vessel and nerve compression may occur and often do not cause symptoms due to the loss of
sensation in the foot.
Management of suspected Charcot’s foot: refer to diabetic clinic urgently.
ACUTE INJURE
CONSIDER ADMISSION/URGENT REFERRAL IF:
• Recent trauma to the foot and or ankle
• Pain may or may not be present
• Swelling
• Muscles wasting
• Reduced function
• New Deformity
• Neurovascular deficit
• Unable/ difficult to weight bear
• Unable to calf raise due to possible Achilles tendon rupture
If suspect a fracture/dislocation/Achilles tendon rupture referral to A&E/fracture clinic.
If suspecting a malignant lesion then MRI within 2 weeks USS via sarcoma pathway.
If suspect malignant tumour refer to east midlands sarcoma clinic:
www.eastmidlandssarcoma.org.uk/making-a-referral

DIAGNOSIS: HIND FOOT/MID FOOT JOINT OA

TYPE OF
GUIDELINES
INFORMATION
Background HIND FOOT
information
Consider the possibility of ankle osteoarthritis as the cause of ankle pain if :-
• 45 or over and
• Has activity-related joint pain
• Has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30
minutes
• Be aware that atypical features, such as a history of trauma, prolonged morning joint-
related stiffness, rapid worsening of symptoms or the presence of a hot swollen joint, may
indicate alternative or additional diagnoses. Important differential diagnoses include gout,
other inflammatory arthritides (for example, rheumatoid arthritis), septic arthritis and
malignancy (bone pain)
• A larger percentage show radiographic changes than have symptoms from ankle OA.
Co-exists with many co-morbidities: obesity, CV disease, psychological dysfunction (loss of
social role, mental health, ‘feeling old’)

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DIAGNOSIS: HIND FOOT/MID FOOT JOINT OA
TYPE OF
GUIDELINES
INFORMATION
Subjective OA
History • Screen for red flags
• Typically in older people or after trauma in younger people
• Symptoms of ankle osteoarthritis are often episodic or variable in severity, and slow to change.
• Use-related pain, often worse towards the end of the day and relieved by rest
• More persistent rest pain and night pain may occur in advanced osteoarthritis.
• Pain that is worse on movement
• Less specific description of pain, vague dull aching
• Describe stiffness in the ankle in the morning or after inactivity lasting 30 minutes or less.
• Reduced function

Examination • Physical examination findings may include:

findings o Difficulty with walking/weight bearing
o Stiffness of joint both active and passively
o Crepitus on ROM
o Painful or restricted movement.
o Bony enlargement around the joint margins and absent or modest effusion (without
warmth).
o Joint line tenderness.
• Functional assessment – activity tolerance, patient-specific limitations in function evaluated
(ie walking distance), must include gait assessment.
• Assess joints above and below

Investigations • Suspected Ankle OA - Weight bearing X-ray AP and lateral Ankle

• If mod-severe symptoms to mid foot (e.g. talonavicular joint) or ankle joints – refer for MRI
to help differentiate pathology and will help guide management (such as specific target for
injection).
• This is especially relevant if referring the patient to the community clinic at Ashfield HWB
Centre for a second opinion
• Or
• Podiatric surgery team can also offer US guided injections- to consider this as an additional
referral route
• Consider bloods if diagnosis unclear –
o Be aware that atypical features, such as a history of trauma, prolonged morning joint-
related stiffness, rapid worsening of symptoms or the presence of a hot swollen joint, may
indicate alternative or additional diagnoses. Important differential diagnoses include gout,
other inflammatory arthritides (for example, rheumatoid arthritis), septic arthritis and
malignancy (bone pain).

Conservative • Assess the severity of pain and the effect of osteoarthritis on the individual’s function, quality
management of life, occupation, mood, relationships, and leisure activities.
• Formulate an individualized management plan in partnership with the person with OA
• Take account of comorbidities that compound the effect of osteoarthritis or the risk of adverse
effects from treatments
• Take into account the person’s expectations, needs, and anxieties. Agree individualised self-
management strategies. Ensure that positive behavioural changes, such as exercise, life
style modifications, weight loss, use of suitable footwear and pacing, are appropriately
targeted
• Advise the patient there will be good/bad days. To try laced boots to support the foot. Not
usually progressive in nature

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DIAGNOSIS: HIND FOOT/MID FOOT JOINT OA
TYPE OF
GUIDELINES
INFORMATION
Conservative • The core treatments to be offered to everyone with osteoarthritis is:
management o Education, advice, and access to information
o Range of movement and strengthening exercise, along with aerobic fitness training
o Weight loss if the person is overweight or obese
o Assistive devices (for example, walking sticks) for people who have specific problems with
activities of daily living or poor balance
• Possible adjuncts to their core treatments are:
o Consider a referral to MSK podiatry or orthotics(for reasons such as to cushion and
support the area of the foot which has OA such as the forefoot/mid foot)
o The use of local heat or cold therapy
Treatments not indicated
• Acupuncture not currently indicated
• Electrotherapy not indicated except for Tens for pain relief
• Nutraceuticals (glucosamine or chondroitin products)
Pharmacological management
Currently being reviewed by NICE and to currently use the 2008 guidelines.
• Healthcare professionals should consider offering paracetamol for pain relief in addition to
core treatments regular dosing may be required. Paracetamol and/or topical non-steroidal
anti-inflammatory drugs (NSAIDs) should be considered ahead of oral NSAIDs, cyclo-
oxygenase 2 (COX-2) inhibitors or opioids. [2008]
• If paracetamol or topical NSAIDs are insufficient for pain relief for people with osteoarthritis,
then the addition of opioid analgesics should be considered. Risks and benefits should be
considered, particularly in older people. [2008]
Follow up and review periodically according to the individual’s needs.

Referral on for If no improvement after 6 months of conservative management including the appropriate core
podiatric surgery treatments consider referral to foot and ankle specialist ( Orthopaedic or community podiatric
or Orthopaedic surgeon) (see criteria).
opinion
If the patient is struggling despite treatment from primary-intermediate care settings at any point,
please consider referral to foot and ankle specialist.
The foot and ankle community clinic at AHV can be used for a second opinion if the clinician is
unsure on whether secondary care management is required.
Referral to or discussion with the podiatric surgeon can should also be considered as a referral
route for suitable patients.
Image guided injections may be considered - Note that this cannot be requested as a
discussion patient within the community clinics at Ashfield as the consultant would like to meet
the patient and gain informed consent.
Consider referral for joint surgery for people with osteoarthritis who experience joint symptoms
(pain, stiffness and reduced function) that have a substantial impact on their quality of life and
are refractory to non-surgical treatment. [NICE 2014]
Refer for consideration of joint surgery before there is prolonged and established functional
limitation and severe pain. [NICE 2014]
Ref -NICE- Osteoarthritis: care and management (2014),
NICE osteoarthritis (2008)

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DIAGNOSIS: HIND FOOT/MID FOOT JOINT OA
TYPE OF
GUIDELINES
INFORMATION
Referral on for Surgical Treatment options
podiatric surgery
or Orthopaedic • These are typically considered when there has been a failure to improve with conservative
opinion management and the patient is keen to explore surgical options via a shared decision-
making process.
Surgical Treatment options for Ankle OA:
• Total Ankle Arthroplasty (TAA) and Ankle Fusion (arthrodesis) are considered the primary
surgical treatments. Ankle Fusion is still seen as the gold standard due to higher risks of
failure/revision rate TAA.
• The consultant surgeon would explain the risks of the surgery to ensure an informed decision
(local anaesthetic risks, nerve injury, infection, DVT, pulmonary embolism, swelling, scar
tenderness, non-union, metalwork problems, persistent pain syndrome due to nerve
irritation).
• Limitations of Ankle Fusion can also include reduced normal ankle motion which can
accelerate joint degeneration at other segments. (Lawton et al 2017).
• Ankle fusion is a major operation requiring significantly long rehabilitation period – the patient
is in plaster for 6/52, then a boot for 6/52 and can take 6/12 up to a year to significantly
benefit from the operation in terms of improvements to pain and function.
Ref - Lawton et al 2017 Total ankle arthroplasty versus ankle arthrodesis - a comparison of
outcomes over the last decade. Journal of Orthopaedic Surgery and Research.

DIAGNOSIS: MID FOOT - OA

TYPE OF
GUIDELINES
INFORMATION
Background See NICE guidelines on OA.
information
Subjective • Subjective symptoms of stiffness and pain.
history • Age: 45 years old and above
• Risk Factors such as hypertension, high BMI and type 2 DM.

Examination • Restrictions to passive and active movements midfoot

findings • Positive squeeze

Investigations • Weight bearing X-ray AP, Oblique & Lateral

• If severe OA needs MRI to help differentiate which joints are affected as this will guide
treatment

Conservative • ROM and Strengthening exercises and consider physiotherapy/podiatry (if having problems
management regaining movement, strength and function after 6-12 weeks self-help )
• Weight reduction programme
• Lifestyle modifications
• Orthotics/supportive footwear

Referral on for • If severe OA seen as may consider ultrasound guided injections.

orthopaedic or • MRI helps to identify joints requiring USGI.
podiatric surgery • Referral on for orthopaedic or community podiatric surgeon opinion
opinion

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DIAGNOSIS: MUSCLE AND LIGAMENTS/SPRAIN/STRAIN
TYPE OF
GUIDELINES
INFORMATION
Background SPRAINS
information
A stretch and/or tear of a ligament (a strong band of tissue that connects the end of one bone
to another).
Sprains are classified by severity as:
• Grade I - mild stretching of the ligament complex without joint instability.
• Grade II - partial rupture of the ligament complex without joint instability.
• Grade III - complete rupture of the ligament complex with instability of the joint.
A strain (or ‘pull’) is a stretch and/or tear of muscle fibres and/or tendon (fibrous cord of
tissue that attaches muscles to bone).
o Strains are classified by severity as :
• First-degree (mild) strain - only a few muscle fibres are stretched or torn. Although the
injured muscle is tender and painful, it has normal strength but power may be limited by
pain.
• Second-degree (moderate) strain - there are several injured fibres and more severe
muscle pain and tenderness. There is also mild swelling, noticeable loss of strength, and
sometimes a visible bruise.
• Third-degree (severe) strain - the muscle tears all the way through, sometimes producing
a ‘pop’ sensation as the muscle rips into two separate pieces or shears away from its
tendon. There is a total loss of muscle function, severe pain and swelling, a visible bruise,
and difficulty bearing weight.
Causes and risk factors
Sprains occur as a result of abnormal or excessive forces applied to a joint.
Strains occur either because a muscle has been stretched beyond its limits or it has been
forced to contract too strongly.
• The risk of strains and sprains is high in people who frequently participate in sport.
Factors that increase the risk of injury during sports include:
o The type of sport - for example, contact sports (such as football, hockey, and boxing) and
sports that feature quick starts (such as hurdling, long jump, and sprinting) increase the
risk of strains;
o Strength and flexibility - a lack of regular exercise can weaken muscles and joints, making
them less flexible and hence more prone to injury.
o Overload - this can cause excessive pressure to be applied to particular joints or
muscles, thereby increasing the risk of injury.
o Wearing inappropriate footwear - this can increase the risk for developing ankle sprains
and strains.
o Inadequate warm up before exercising, and cool down after exercising.
o Muscle fatigue - tired muscles are less likely to provide adequate support for the joints.
• Other risk factors for sprains and strains include:
o Sudden trauma, for example; a fall, twist, or blow to the body.
o Anatomical variations of the foot and ankle (for example generalized joint laxity or flatfoot)
- these may predispose a person to chronic injury.
o Type of muscle - some muscle types are more prone to injury than others, for example:
• More pennate muscles (short muscle fibres that extend from a central tendon) have a
greater percentage of elongation before failure than less pennate muscles.
• Fast-twitch muscle fibres are more prone to injuries than slow-twitch muscle fibres.
• Muscle-tendon units that span two joints, for example the rectus femoris (which spans the
hip and knee joints), are more commonly injured.
o Medical conditions that predispose to falls (for example epilepsy or balance disorders).
o Excessive alcohol intake and the use of drugs that can cause drowsiness (for example
opioid analgesics).
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DIAGNOSIS: MUSCLE AND LIGAMENTS/SPRAIN/STRAIN
TYPE OF
GUIDELINES
INFORMATION
Background o Being overweight or obese - this can put pressure on the joints and muscles.
information o Previous sprain or strain.
• Sprains and strains are common, especially in people who frequently participate in sport
and when there are predisposing factors .
o About 30-50% of musculoskeletal injuries that present in primary care are tendon and
ligament injuries, with ankle injury being the most common in both athletes and sedentary
people.
o CKS was unable to find specific UK incidence or prevalence data; however, in the US,
musculoskeletal injuries account for about 2 million injuries per year and 20% of all sports
injuries.

Subjective • Symptoms of a sprain typically include:

history
o pain around the affected joint,
o tenderness,
o swelling,
o bruising,
o functional loss (for example pain on weight-bearing),
o mechanical instability (if the sprain is severe).
• Symptoms of a strain typically include:
o muscle pain,
o spasm,
o weakness,
o inflammation, and/or cramping.
o Large haematomas can occur as a result of tearing of the intramuscular blood vessels.
o There may be obvious swelling, although small haematomas or those deep within the
muscle are more difficult to diagnose clinically.
o The severity of symptoms will depend on the severity of the injury as well as the time since
the injury. For example, it can take up to 24 hours for the full extent of bruising to become
apparent.
o Symptom duration of more than a few days can suggest more severe injury.
o Any predisposing or risk factors, such as a medical condition or previous sprain or strain
(enquire about the management and outcome).
o Any complicating factors, such as medication that may affect the injury (for example
anticoagulants) or a complicating illness (for example neuropathy, bleeding disorder, or
history of deep vein thrombosis

Examination Sprains:
findings
• pain around the affected joint,
• swelling,
• bruising if acute
• functional loss (for example pain on weight-bearing),
• mechanical instability (if the sprain is severe) – tests such as AP drawer, Talar tilt could be
positive, but should not be used in isolation to diagnose sprains.
• Squeeze test (if positive it could indicate syndesomotic sprains)
Strain:
• muscle pain,
• spasm
• weakness
• swelling
• haematoma may be present

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DIAGNOSIS: MUSCLE AND LIGAMENTS/SPRAIN/STRAIN
TYPE OF
GUIDELINES
INFORMATION
Investigations ANKLE X-RAY
Following an ankle injury, an ankle x-ray is typically only required if there is pain in the
malleolar zone AND one of the following:-
• Inability to bear weight (walk four steps) immediately after the injury and when examined.
• Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral
malleolus.
• Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial
malleolus
(the reason for the ankle x-ray would be to check for underlying fracture – Ottawa Rules)
ANKLE MRI
The APP/consultant may order an ankle MRI If there is persistent pain and giving way following
a traumatic injury. Reasons would be to check for osteochondral lesion or severe ligament
damage which may require repair.

Conservative • Offer analgesia for pain relief.

management
o Prescribe paracetamol or a topical nonsteroidal anti-inflammatory drug (NSAID, such as
ibuprofen gel).
o Codeine can be used as an ‘add on’ to paracetamol, if necessary.
o Consider prescribing an oral NSAID (for example ibuprofen or naproxen) 48 hours after the
initial injury, if needed.
o For detailed information on prescribing paracetamol, ibuprofen, and codeine, see the CKS
topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues.
• If acute Advise the person:
o To manage their injury using the PRICE measures:
o To avoid HARM in the first 72 hours after the injury:
• Heat - for example hot baths, saunas, and heat packs.
• Alcohol - increases bleeding and swelling and decreases healing.
• Running - or any other form of exercise which may cause further damage.
• Massage - may increase bleeding and swelling.
• Consider the need for immobilisation.
For sprains:
o
• If severe, a short period of immobilisation can result in quicker recovery.
• For less severe sprains, it is advisable not to immobilise the joint. Begin flexibility (range
of motion) exercises as soon as they can be tolerated without excessive pain and when
able strengthening and functional exercises
o For strains:
• Immobilise the injured muscle for the first few days after the injury. Consider the use of
crutches in severe injuries.
• Start active mobilisation after a few days if the person has pain-free use of the muscle
in basic movements and the injured muscle can stretch as much as the healthy
contralateral muscle and progress to strengthening and functional exercises
• Advise the person to seek further medical advice in 5-7 days or consider referral to
physiotherapy if there is:
o Lack of expected improvement (for example they have difficulty walking or bearing weight).
o Worsening of symptoms (for example increased pain or swelling).
o Presence of yellow flags

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DIAGNOSIS: MUSCLE AND LIGAMENTS/SPRAIN/STRAIN
TYPE OF
GUIDELINES
INFORMATION
Conservative • Manage patient expectations – For example, it can take 9 months to return to full function
management and sport following an ankle sprain. Set short term and long term goals to facilitate self-
efficacy and motivation with rehabilitation.
• Advise that the person should:
o Take care when exercising or doing sport. They should:
• Warm up before exercising (by doing an aerobic activity at an easy pace to gently
increase the heart rate and get the body and muscles ready for more intense activity).
• Cool down after exercising (by gradually decreasing the exercise intensity level until
breathing and heart rate have returned to normal, then doing gentle stretches whilst the
muscles are still warm).
• Use proper equipment.
• Wear appropriate shoes, and replace shoes as they wear out.
• Wear comfortable, loose-fitting clothes that allow free movement.
• Develop a balanced fitness program that incorporates cardiovascular exercise, strength
training, range of movement and proprioception – they may need physiotherapy to assist
with this
• Add activities and new exercises in a graded manner.
• Avoid exercising or playing sport when tired or in pain which is not manageable.
• Schedule regular days off from exercise.
o Practice safety measures to help prevent falls, such as keeping stairways and walkways
free of clutter, using anti-slip mats under rugs, clearing ice and snow from footpaths in the
winter, and wearing appropriate footwear in icy conditions (flat footwear with rubber soles
rather than leather-soled or high-heeled shoes).
o Take particular care when taking drugs that cause drowsiness (for example opioid
analgesics) or if they have a medical condition that predisposes them to falls (for example
epilepsy or balance disorders).
o Avoid getting drunk.
o Maintain a healthy weight.
Referral on for • Consider the need for referral to an orthopaedic foot and ankle specialist
orthopaedic (urgency depending on the severity of symptoms and clinical judgement) if:
opinion
o Recovery is slower than expected. If no improvement at all after 3 months of conservative
management, consider referral to foot and ankle specialist
o There are worsening or new symptoms.
o Symptoms are out of proportion to the degree of trauma.
o Note - Sprains and strains are often not amenable to surgical intervention
• The prognosis of a sprain or strain largely depends on the severity of the injury
[ Jarvinen, 2000 ] [ BMJ, 2015 ] .
o A mild injury will usually heal within a few weeks with conservative treatment, with minimal
long-term complications.
o A moderate injury should heal within a few weeks, but there is a high risk of further injury in
the first 4-6 weeks.
o A severe injury may take months to heal fully (such as 9 months for a severe ankle sprain),
and result in complications, such as:
• For severe sprains – chronic instability, loss of function, pain, and secondary
degenerative changes in the affected joint.
• For severe strains – muscle atrophy, muscle fibrosis, heterotrophic ossification, and
compartment syndrome.

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DIAGNOSIS: MUSCLE AND LIGAMENTS/SPRAIN/STRAIN
TYPE OF
GUIDELINES
INFORMATION
Referral on for • In general:
orthopaedic
o If a person with an ankle sprain has an uncomplicated recovery, walking is usually possible
opinion
within 1-2 weeks, with function restored after 6-8 weeks, and a return to sporting activities
after 8-12 weeks (depending on the severity of the injury) [ de Bie et al, 2006 ]. Severe
ankle sprains can result in prolonged time away from sport (9 months).
o With ankle sprains, pain and intermittent swelling (particularly on the lateral side of the
ankle) are the most common residual problems [ Struijs and Kerkhoffs, 2010 ] .
Ref- NICE CKS sprains and strains (2016)

CRITERIA FOR REFERRAL TO COMMUNITY PODIATRY SURGEONS

(NOTTINGHAMSHIRE HEALTH CARE PODIATRIC SURGEONS)
TYPE OF
GUIDELINES
INFORMATION
Inclusion criteria Indications for assessment or treatment with the Podiatric Surgery team
• Hallux Abducto Valgus (HAV) or ‘bunions’
• Hallux Limitus/Rigidus
• Hammer/Mallet toe or any other digital deformities
• Tailors Bunion
• Metatarsalgia
• Traumatic injuries of the foot
• Chronic recalcitrant foot pain
• Painful skin lesions (only if community podiatry fails)
• Nail disorders (only if community podiatry fails)
• Sesamoid Pain
• Subungal Exostosis
• Intermetatarsal Neuroma or traumatic neuroma
• Painful Haglund’s deformity
• Painful Accessory Ossicle
• Osteochondrosis
• Osteoarthritis of foot Joints
• Soft tissue lumps and bumps
• Tendon disorders of the foot & lower leg
• Previous foot surgery with complications
• Diabetes related foot disease
Exclusion criteria Contra-indications for day case surgery
• Unstable systemic diseases
• Peripheral vascular disease
• Lack of postoperative support
• Unstable Psychiatric disorders
• Severe acute anxiety
• Recent or unpredictable drug or alcohol abuse
• Anti-coagulant therapy with INR>3
• Consider referral to secondary care* when GA or IV sedation is requested
• Consider referral to secondary care if inpatient care is required
• Podiatric surgery team at Newark offer surgery under GA

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DIAGNOSIS: HIND FOOT/TENDONS/TENDINOPATHIES
TYPE OF
GUIDELINES
INFORMATION
Background Achilles tendinopathy
information
Achilles tendinopathy is a soft tissue disorder which causes pain, stiffness, and swelling of the
Achilles tendon.
The Achilles tendon is the longest (approximately 12–15cm) and strongest tendon in the body.
It attaches the gastrocnemius and soleus muscles in the lower leg to the heel bone (calcaneus)
• Mid-portion or mid-substance tendinopathy affects an area of the Achilles tendon
approximately 2–6 cm above its insertion on the calcaneus. This area is vulnerable to damage
because it has a relatively poor blood supply. Mid-portion tendinopathy is the most common site
of Achilles tendon damage (about 75% of cases).
• Insertional tendinopathy affects the insertion of the Achilles tendon on the posterior
calcaneum. This occurs in about 25% of cases.
• The term ‘Achilles tendinitis’ is no longer used as histopathology studies have shown that
the predominant process in Achilles tendinopathy is degenerative (‘tendinosis’) rather than
inflammatory (‘tendonitis’).
• Risk factors for Achilles tendinopathy include:
o Overuse or strenuous physical activity, for example running and jumping.
o Ageing - the majority of tendons undergo degenerative changes with increasing age.
o Biomechanical factors:
• Intrinsic factors include leg length discrepancy, an overly pronated foot, tight or
underdeveloped hamstrings, a high-arched (pes cavus) foot, and lateral instability of the
ankle.
• Extrinsic factors include poor equipment (such as inappropriate footwear), changes to
training regimen or poor training techniques (such as a sudden increase in intensity),
previous injury, and environmental factors (such as training on hard surfaces or hills, and in
cold weather).
• Other factors thought to contribute to the development of Achilles tendinopathy include:
o Use of fluoroquinolone antibiotics, such as ciprofloxacin.
• Achilles tendinopathy has been reported in 6% of people who have taken fluoroquinolone
antibiotics.
• A cohort study in Denmark found that the incidence of Achilles tendon rupture within 90
days of taking fluoroquinolones is three times higher than the background population [Sode,
2007].
• A systematic review found that 5 out of 16 observational studies stated that people taking
oral corticosteroids and fluroquinolones were at greater risk of tendon injury that those
taking fluroquinolones alone [Stephenson, 2013]
• Fluoroquinolone treatment should be discontinued at the first signs of a serious adverse
reaction, including tendon pain or inflammation (MHRA March 2019)
o Male sex.
o Rheumatoid arthritis or other inflammatory joint disease (such as psoriatic arthritis or reactive
arthritis) - usually related to insertional tendinopathy.
o Family history - the chance of developing Achilles tendinopathy has been reported to be five
times higher in people with a positive family history.
o Dyslipidaemia.
o Type 1 and Type 2 diabetes mellitus.
o Obesity.
o Hypertension.
[Sode, 2007; Carcia, 2010; Scott, 2011; Wilson, 2010; DTB, 2012; Asplund, 2013; Childress,
2013]

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DIAGNOSIS: HIND FOOT/TENDONS/TENDINOPATHIES
TYPE OF
GUIDELINES
INFORMATION
Background CAUSES
information
• Repetitive strain and microtrauma to the Achilles tendon during activities such as running
(including sudden acceleration or deceleration), and jumping make it susceptible to injury and
degeneration.
• Psychosocial factors such as low self- efficacy, fear avoidance and catastrophisation can
contribute to the initial pain response and the prognosis in terms of whether the condition
improves.
• The normal process of tendon repair after injury involves:
o An acute inflammatory phase which lasts a few days.
o A proliferative phase, lasting approximately 3 weeks, where fibroblasts produce new collagen
and new vessels form.
o A collagen remodelling phase which can last up to a year.
• This normal healing response fails in Achilles tendinopathy and instead, cells and vessels
proliferate in a disorganised way and collagen fibres degenerate.
[Wilson, 2010; DTB, 2012; Sussmilch-Leitch, 2012; Asplund, 2013; Childress, 2013]
DIFFERENTIAL DIAGNOSIS
True tendon pain (from rupture or tendinopathy) is usually confined to the tendon itself
Other diagnoses which cause pain in and around the Achilles tendon include:
o Achilles tendon rupture - partial or complete rupture
o Retrocalcaneal bursitis - the retrocalcaneal bursa lies between the calcaneum and the
Achilles tendon
o Plantaris tendinopathy - the plantaris muscle lies deep to the gastrocnemius muscle and is
found in 7–20% of people. Injury to the plantaris muscle can produce symptoms that are
similar to Achilles tendinopathy
o Dislocation of the peroneal or other plantar flexor tendons (would need MR and surgical
intervention)
o Posterior ankle impingement - this causes pain on forced plantar flexion when jumping or kicking
o Ankle osteoarthritis
o Tendon xanthoma - associated with severe hypercholesterolemia and can appear as nodules
related to the Achilles tendon
o Haglund’s deformity - a posterolateral calcaneal prominence (sometimes called a ‘pump
bump’) which can become inflamed. If symptomatic typically requires either foot wear
modification and orthotics to stabilise the calcaneous. Referral to MSK podiatry or orthotics
service may be appropriate
o Os trigonum syndrome — a floating bone just behind the ankle joint
o Calcaneal apophysitis — Sever’s disease of adolescents
o Calcaneal stress fracture
o Irritation or neuroma of the sural nerve or sacral root pain
o Systemic inflammatory disease, such as rheumatoid arthritis — consider this if there are
bilateral or systemic signs
Other common foot and ankle tendinopathies to consider are :
• Tibialis posterior- Pain and swelling posterior to the medial malleolus. Pain worse with weight
bearing and with inversion and plantar flexion against resistance
• Peroneal-Pain and swelling posterior to the lateral malleolus. Pain with active eversion and
dorsiflexion against resistance. May have a history of chronic lateral ankle pain and instability
• Flexor hallucis longus- Pain and swelling over the posteromedial aspect of the ankle. Seen
in dancers or athletes who use repetitive push-off manoeuvres. Pain with resistive flexion of the
great toe
• Anterior tibial- Pain over the anterior ankle Weak dorsiflexion of the foot Caused by forced
dorsiflexion

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DIAGNOSIS: HIND FOOT/TENDONS/TENDINOPATHIES
TYPE OF
GUIDELINES
INFORMATION
Subjective ACHILLES TENDON
History
• Ask about symptoms that might indicate Achilles tendon rupture,
o Sudden intense pain in the back of the leg, and inability to walk or carry on with the
precipitating activity.
• Ask about typical symptoms of Achilles tendinopathy including:
• Pain in the back of the leg or heel:
• Pain is usually intermittent, worse in the morning, and aggravated by activity or exercise.
• Stiffness in the tendon.
• Stiffness may occur in the morning or after a period of immobility, and ease with movement.
• Ask how symptams are affecting function:
Ask about risk factors such as diabetes mellitus, dyslipidaemia, and fluoroquinolone use.

Examination Examine both legs:

findings
o Exclude Achilles tendon rupture. If no evidence of an Achilles tendon rupture is found:
• Look for swelling, deformity, and any signs of inflammation.
• Palpate along the length of the tendon for tenderness, heat, crepitus, localized thickening,
and nodularity.
• Assess function by asking the person to perform a tendon-loading activity — in most
people, simple single-leg heel raises are sufficient. More active people may need to hop
on the spot to reproduce pain.

Investigations • Achilles tendinopathy is usually a clinical diagnosis and imaging (such as ultrasound
or MRI) is not routinely recommended in primary care.
Reasons for X-ray – if referring for orthopaedic consultant opinion
• If the patient has insertional tendinopathy - you may want to consider X-ray to check for
Haglund’s deformity (“Pump bump”). Lateral weight bearing and calcaneal axial views may be
helpful. An x-ray is not required for mid-achilles tendinopathy.
• It is useful to determine if Haglund’s deformity is evident when secondary care or community
podiatric surgery intervention (surgery, injections) could be indicated. This is because the
prognosis can be worse with the presence of a Haglunds deformity and also because during
surgical intervention, the bony prominence would be shaved as part of the procedure. During
surgical intervention the Achilles may have to be detached and debrided. This adds to the
time taken to recover- typically 12-18 months. The patient would also be advised that a lump
could still remain post treatment.
Alternative investigations
• Arrange investigations (such as lipid profile or HbA1c) as appropriate, if an underlying
systemic cause is suspected.

Conservative • If Achilles tendon rupture has been excluded:

management • Explain that the symptoms of Achilles tendinopathy usually take 12 weeks to resolve.
• Manage as appropriate any underlying causes, such as:
• Fluroquinolone antibiotics — discontinue (discuss with microbiology if unsure regarding
alternatives).
• Hypercholesterolemia - see the CKS topics on Hypercholesterolaemia - familial and Lipid
modification - CVD prevention for further information.
• Diabetes mellitus - see the CKS topics on Diabetes - type 1 and Diabetes - type 2 for further
information.

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DIAGNOSIS: HIND FOOT/TENDONS/TENDINOPATHIES
TYPE OF
GUIDELINES
INFORMATION
Conservative • Advise the person that:
management
• Cold packs or ice can be applied to ease symptoms after acute injury.
• Paracetamol can be used for pain relief — nonsteroidal anti-inflammatory drugs (NSAIDs)
may be useful for analgesia in the acute phase but are not recommended in the longer
term. See the CKS topics on Analgesia - mild to moderate pain and NSAIDS - prescribing
issues for more information.
• Manage the patient’s loading strategies to facilitate a graded return to previous function. .
• Refer the person to physiotherapy:
• For assessment and supervised graded loading exercises if their symptoms fail to improve
within 7–10 days.
• For all tendon-related issues – consider any psychosocial factors as well as physical factors
that may delay or inhibit recovery and address accordingly. Facilitate self-efficacy and
manage patient expectations effectively through appropriate advice, reassurance and short-
term/long-term goal setting.
• Adjuncts - Orthotics for a heel lift can be used to ease symptoms and aid recovery. (a rigid
12mm heel lift used temporarily might be a simple, cost-effective and potentially beneficial
intervention).

Referral on for • Most people with Achilles/Tibialis posterior/peroneal tendinopathy improve with conservative
orthopaedic treatment. Pain and function usually improve after 12 weeks of conservative treatment.
opinion • If the patient is not improving within 12 weeks, consider referral to orthopaedics (foot and
ankle specialist) in the community clinics (if ongoing management plan is not clear and need
further guidance) or as a secondary care referral (if the management strategy is clear i.e. the
APP feels there is a clear surgical target).
• For an insertional tendinopathy AND ankle X-ray has been performed – this could be booked
as a discussion patient at AHWB community clinic for consideration of USGI ordering from
consultant.
• For a mid-portion tendinopathy – USGI not ideal due to possible rupture rate. May consider
high volume saline injections by needling or PRP - will need review with consultant which can
be in the Ashfield community clinic or referral into secondary care
SURGERY
Surgery is very rarely performed for these patients.
• Prognosis
• One follow-up study of people with Achilles tendinopathy found that 8 years after
injury [Paavola et al, 2000]:
• 84% of people with Achilles tendinopathy had completely returned to their normal activity
level and 94% were asymptomatic or had only mild pain with strenuous exercise.
• 40% had developed problems with their other Achilles tendon and 29% needed surgery.
• Achilles tendinopathy becomes more resistant to treatment if it is not recognized and
managed at an early stage.
[Paavola et al, 2000; Asplund, 2013]
Ref Nice CKS Achilles tendinopathy (2016)

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DIAGNOSIS: PLANTAR FASCIITIS
TYPE OF
GUIDELINES
INFORMATION
Background Plantar fasciitis is a condition in which there is persistent pain associated with chronic
information degenerative and reparative processes affecting the origin of the plantar fascia and surrounding
peri-fascial surfaces
• It accounts for about 80% of cases of heel pain, with a lifetime prevalence of around 10%
and is most common in people 40–60 years of age
• Plantar fasciitis is usually diagnosed by clinical findings alone; if characteristic signs and
symptoms are present the diagnosis is likely to be accurate
DIFFERENTIAL DIAGNOSIS
If characteristic symptoms and signs are not consistent with plantar fasciitis, consider
the following:
• Achilles tendonitis presents with tenderness on the posterior-superior aspect of the heel and
along the Achilles tendon on palpation, with pain radiating up the calf with extension of
the foot or when standing on tiptoes (complete rupture causes severe pain and loss of foot
stability). It is caused by activities associated with overuse of the calf muscles such as
running, and wearing high heels.
• Flexor hallucis longus tendinopathy may mimic plantar fasciitis, but can be differentiated
from it by pain with resisted plantar flexion of the big toe. Tenderness is posterior to the
medial malleolus on the plantar surface of the big toe.
• Calcaneal stress fracture, which typically presents with diffuse, warm swelling, and can be
diagnosed by squeezing the calcaneum, inducing pain. Typically it occurs in a person who
has walked a long distance carrying a heavy pack. The pain initially occurs with activity but
rest pain may develop. It is confirmed by radiography, although changes may be subtle or
even absent.
• Fat pad atrophy which causes centralized heel pain, and a flattened atrophied surface may
be felt on palpation. Suspect if there is a history of trauma such as landing on the heel. This
is also common in elderly people who are obese, and in athletes who train on hard surfaces.
Walking barefoot or on hard surfaces exacerbates the pain.
• Sub-calcaneal bursitis is most common in the elderly, and athletes who have done a lot of
running, walking or jumping. The person presents with posterior heel pain under the fat pad
of the calcaneum. Unlike plantar fasciitis it is not made worse by dorsiflexion of the toes.
• Other causes less likely to be misdiagnosed as plantar fasciitis:
NEUROLOGICAL CAUSES:
• Tarsal tunnel syndrome presents with poorly localized pain, numbness, and burning on
the medial side of the foot, ankle, and sometimes the calf that is worsened with standing and
walking. Reproduction of the symptoms with Tinel’s test supports the diagnosis. This involves
tapping with fingers or a tendon hammer over the tibial nerve which runs below and posterior
to the medial malleolus, on a dorsiflexed, everted foot. Unlike plantar fasciitis, dorsiflexion of
the toes does not make the pain worse.
• An L5-S1 radiculopathy may cause plantar heel pain. It can be ruled out by a comprehensive
neurological examination.
• Nerve entrapment (such as lateral plantar and medial nerves) can mimic plantar fasciitis, but
tends not to specifically affect the medial tuberosity. In particular, the first branch of the
lateral plantar nerve may present with tenderness on the medial side of the edge of the heel,
with pain radiating to the lateral side of the heel.
• Peripheral neuropathy lacks a specific focal area of pain and sensations may still be felt at
rest.

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DIAGNOSIS: PLANTAR FASCIITIS
TYPE OF
GUIDELINES
INFORMATION
Background Other musculoskeletal causes including:
information
• Plantar fascia rupture, which presents as a sudden onset of pain and bruising. There may be
a palpable gap and evidence of collapse in the medial longitudinal arch.
• Plantar fibromatosis which causes pain in the mid-section of the plantar fascia and palpable
nodules.
• Fracture of the calcaneum caused by landing on the heel from a height. The person is not
able to weight bear.
• Infection (osteomyelitis or subtalar pyoarthrosis) which is rare in the absence of an open
wound. It presents with a red, hot, swelling and systemic illness.
• Haglund deformity, which is a prominence of the superior aspect of the posterior calcaneus.
Repeated pressure such as from ill-fitting shoes can lead to retrocalcaneal bursitis.
• Retrocalcaneal bursitis, which presents as pain, redness, swelling and tenderness to
palpation between the calcaneus and Achilles tendon.
• Sinus tarsi syndrome which is caused by repeated hyperpronation of the foot or lateral ankle
sprains. The talocalcaneal sulcus (sinus tarsi) is the anatomical space bounded by the talus,
calcaneus, talocalcaneonavicular joint and posterior facet of the subtalar joint. Pain is worse
when walking on an uneven surface, and after exercise.
• Inflammatory arthropathies, and gout can be ruled out by appropriate investigations.
• Neoplasm and vascular insufficiency are very rare causes of heel pain (but should be
considered in recalcitrant cases).

Subjective • Ask about the nature of the heel pain, and the general health and physical activity of
history the person
• Characteristic symptoms of plantar fasciitis include:
• An initial insidious onset of pain.
• Intense pain during the first steps after waking or after a period of inactivity.
• Lessening pain with moderate foot activity, but worsening later during the day or after long
periods of standing or walking.
• Document any risk factors
• Plantar fasciitis most commonly affects people 40–60 years of age who are overweight or
obese, or who are on their feet for extended periods.

Examination • Examine the foot at rest (when sitting), and when standing and walking.
findings
• Tenderness on palpation of the plantar heel area (usually, localized around the medial
calcaneal tuberosity) is a defining sign of plantar fasciitis.
• Limited ankle dorsiflexion range (with the knee in extension) and a positive ‘Windlass
test’ (reproduction of pain by extension of the first metatarsophalangeal joint) is suggestive
of plantar fasciitis.
• Abnormal walking/limping due to pain may be observed.

Investigations • None indicated in initial stages

• MRI/CT if symptoms do not improve or for differential diagnosis

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DIAGNOSIS: PLANTAR FASCIITIS
TYPE OF
GUIDELINES
INFORMATION
Conservative • Self-help advise the person to:
management
o Rest the foot (by avoiding standing or walking for long periods) where possible.
o Wear shoes with good arch support and cushioned heels (such as laced sports shoes) and
avoid walking barefoot.
o Advise purchasing insoles and heel pads to insert in the shoe, with the aim of correcting
foot pronation (however ‘magnetic’ devices should be avoided).
o Lose weight if overweight to prevent future episodes.
o Apply ice for 15-20 minutes
o Take analgesia on an ‘as required’ basis to relieve pain.
o Recommend self-physiotherapy to include Ankle DF stretches in non-weight bearing and
weight bearing positions.
• Refer people with mild symptoms to a podiatrist or physiotherapist if self-care has
not been effective after a few months.
o Consider earlier referral to a physiotherapist and or podiatrist for people with more severe
symptoms that are having a significant impact on their ability to function normally.
• Physiotherapy for loading and strengthening work and support with graded return to normal
activities to promote long-term resolution of plantar fasciitis.
• Orthotics for soft heels / night socks / splints
• In some circumstances short-term relief of symptoms by injecting the plantar fascia with a
corticosteroid may be considered appropriate, after considering the following points:
o The injection is often very painful and post-injection pain may last for several days.
o Symptoms commonly return within a month following the injection.
o Rarely a corticosteroid injection can cause fat pad atrophy or plantar fascia rupture.
• If the initial treatment was beneficial but symptoms return, the treatment may be repeated
once with a minimum of 6 weeks between injections.
• Preference is for a ultrasound guided injection as can often locate exactly the most
problematic area. If fails would consider PRP injection
• These patients can be booked in a discussion slot at the Ashfield consultant clinics for
booking of USGI if pains are located to under the heel.

Referral on for • Consider referral to an orthopaedic or podiatric surgeon if pain persists for up to 6 months
orthopaedic with no improvement after treatment by a physiotherapist or podiatrist, which has included
or podiatric strengthening rehabilitation
surgeon opinion • Specialist treatments that may be offered include:
• Ultrasound guided steroid injections or PRP injections.
Prognosis
The long-term prognosis for plantar fasciitis is good. One prospective survey found that over
80% of people achieved complete resolution of their symptoms within a year

Ref- https://cks.nice.org.uk/plantar-fasciitis#!topicsummary

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DIAGNOSIS: FOREFOOT PAIN- MORTON’S NEUROMA
TYPE OF
GUIDELINES
INFORMATION
Background Important to differentiate benign lesions from aggressive benign or malignant lesions.
information (Clinicians should check for red flags that could indicate sinister pathology such as a cancerous
tumour and refer to the appropriate specialist services).
Morton’s neuroma is a nerve entrapment condition in which there is a benign neuroma of the
common plantar digital nerve(s) which can cause severe pain/paraesthesia.
The condition can occur in one foot or both feet. It usually affects the nerve between the third
and fourth toes, but sometimes the second and third toes are affected.
Morton’s neuroma can occur at any age, but most often affects
• Middle-aged (40-60 year olds)
• 4-15 times more common in women
• May be because women tend to wear tight or high-heeled shoes that can put pressure on
the feet
• Typically associated with a flexible foot type (in women)
• Increasingly seen in runners, possibly because of the increased pressure on the toes that
occurs when running.

Subjective Mortons neuroma:

history
• Typical symptoms of Morton’s neuroma include:
o Pain in the forefoot, most commonly felt in the third inter-metatarsophalangeal space, less
commonly in the second, and rarely in the first or fourth.
o Pain whilst walking, exacerbated by increased activity or particular footwear, and relieved
by removal of footwear and massaging the toes.
o A sharp, stabbing, burning, or tingling sensation (sometimes described as feeling like an
electric shock) in the distribution of the affected nerve.
• Some people with Morton’s neuroma may be asymptomatic, with the neuroma being
detected as an incidental finding on examination of the foot for another reason
• Mortons neuroma can often be misdiagnosed- consider differential for example Metatarsalgia

Examination • Pain is elicited on applying pressure to the involved inter-metatarsophalangeal space.

findings • Mulder’s click:
• Grip the neuroma between your forefinger and thumb (with your thumb on the plantar aspect
of the foot).
• With your other hand, simultaneously squeeze the metatarsal heads (1–5) together in the
transverse plane.
• A click can be felt and heard as the enlarged nerve subluxes between the metatarsal heads
as they are compressed.
• Absence of this sign does not rule out neuroma.
• Loss of sensation to the affected toes is a strong indicator of Morton’s neuroma, but a
sensory deficit may not be apparent on examination.
Reference: NICE CKS Mortons Neuroma

Investigations • Ultrasound guided injection (there is little point doing an ultrasound on its own if an injection
will be required at the same time)
• At AHV- Mr Chilamkurthi can order an US-guided injection if the patient is booked in as a
“discussion patient” at his AHWB triage clinic
• The APP should use a discussion slot in Mr Chilamkurthi’s community AHWB centre if they
deem an US-guided injection could be of benefit
• Referral to podiatric surgeon should be considered as a referral route for this condition
• If there is no Morton’s neuroma shown on Ultrasound, the radiologist will not inject

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DIAGNOSIS: FOREFOOT PAIN- MORTON’S NEUROMA
TYPE OF
GUIDELINES
INFORMATION
Conservative • If benign/painless-observe and reassure
management • Consider podiatry/podiatric surgery referral
• Advise on footwear and padding/orthotics/insoles
• Weight loss if appropriate
• Ultrasound-guided injection (see above section on “investigations” for Morton’s Neuroma.
This can be ordered via Mr Chilamkurthi’s community triage clinic (use a discussion slot).

Referral on for If no improvement with conservative management consider referral to specialist foot & ankle
orthopaedic or specialist or podiatric surgeon, if patient wishes to consider surgery.
podiatric surgeon
The patient should be made aware of potential risks with surgery, including the potential for
opinion
permanent loss of sensation in the toes, 15% risk of recurrent or stump neuroma formation and
the risk of developing CRPS

DIAGNOSIS: (HALLUX VALGUS/RIGIDUS)

TYPE OF
GUIDELINES
INFORMATION
Background Consider the Procedures of Limited Clinical Value and Procedures Not Funded Policy –
information soft tissue correction of hallux valgus to treat Hallux Valgus is a restricted procedure.
Prior approval form will need to be completed prior to referral to secondary care or to a
podiatric surgery consultant.

Subjective • Pt has noticed hallux valgus deformity

history • Age: typically 45 years old and above
• Risk factors for OA such as hypertension, diabetes mellitus, high BMI.

Examination • Hallux valgus

findings • Restrictions to movement 1st MTP.

Investigations • Weight bearing X-ray AP & Lateral

• An MRI is not indicated to diagnose great toe osteoarthritis

Conservative • Advise on footwear and padding

management • Podiatry
• If mild- Moderate OA to big toe – may consider injection to joints as superficial joint
• Injection could be administered via the APP, MSK podiatry
• X-ray or US guided injections could be offered in secondary care or by podiatric consultant

Referral on for If no improvement after 6-12 weeks of conservative management (depending on severity of
orthopaedic or symptoms) and the patient wishes to consider surgery consider medical optimisation and then
podiatric surgeon refer to Specialist Foot & Ankle Consultant or Podiatric Surgeon.
opinion

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DIAGNOSIS: FOREFOOT PAIN- METATARSALGIA
TYPE OF
GUIDELINES
INFORMATION
Background Metatarsalgia (also known as Metatarsophalageal joint synovitis) is a general term used to
information denote a painful foot condition in the metatarsal region.
It is a common inflammatory condition occurring most frequently in the second, third and/or
fourth metatarsophalangeal joints, or isolated in the first metatarsophalangeal joints.

Subjective • Metatarsalgia typically affects the bottom of the second metatarsophalangeal joint. However,
history any of the other metatarsals can be affected.
• Symptoms of metatarsalgia include:
• Pain and tenderness of the plantar surface of the heads of the metatarsal bones or of the
metatarsophalangeal joint
• Increased pain during the mid-stance and propulsion phases of walking as body weight is
shifted forward onto the forefoot
• The pain is typically described as a deep bruise. Sometimes, it will feel like there is a rock
under the ball of the foot. These symptoms are usually worsened when walking or standing
barefoot on a hard surface or poorly cushioned shoe, and better when in well-cushioned
shoes. At the end of a day, with substantial standing and/or walking, the area can throb.
• The sensation of having a ‘pebble’ or ‘lump’ under the metatarsal region when walking.
• The patient may get symptoms of mortons neuroma, which can be part of the umbrella term
of metatarsalgia (see section on mortons neuroma within this pathway)

Examination • Pain and tenderness of the plantar surface of the heads of the metatarsal bones or of the
findings metatarsophalangeal joint
• Development of callus under the prominent metatarsal heads
• Patients with neuroma will have pain with squeeze test in the region of the 3rd and 4th
metatarsal heads
• Be mindful that in the diabetic population you may not see callus formation and the patient
may not report pain but you may see ulceration of the MTP joint
• Patient may demonstrate subtle inflammation at base of second digit- must compare this to
the other foot
• Assessment of patient in standing- may observe that the lesser toes may be floating and
unable to purchase
• May coexist with flexion deformities at PIP joint (Hammer toes)

Investigations • X-ray Weight bearing and AP lateral

Conservative • Advise on footwear and padding

management • MSK Podiatry/orthotics

Referral on for • If no improvement with conservative management consider referral to specialist foot & ankle
orthopaedic or specialist or podiatric surgeon, if patient wishes to consider surgery.
podiatric surgeon
opinion

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