Musculoskeletal Decision Making Tool

1. Musculoskeletal Decision Making Tool This tool is currently in development and work is underway to refine and enhance flow and ease user interaction

2. Musculoskeletal Decision Making Tool Click over affected area for guidelines / advice / referral guidance Alternatively click on body area below Cervicalspine Thoracic Spine Shoulder Elbow Wrist and Hand LumbarSpine Hip Knee Foot and ankle MSK Pathway General GP Information about Allied Health Professionals General Injection Advice Patient Information Leaflets Contact us Useful websites Please note these MSK orthopaedics / AHP guidelines have been produced as an aide memoire only and are not a substitute for GP / AHP knowledge about their individual patients. NB. Referral Guidelines for Rheumatology remain unchanged

3. Key National MSK programme (Blue) NHS Tayside programme (Yellow) MSK PATHWAY – DRAFT PATHWAY ONE Simple MSK Problem * Self Management and Advice NHS 24 PATHWAY TWO Red Flags Severe Pain, Significantly Decreased Function OR Clear Secondary Care Referral (refer to MSK guidelines) PATIENT GP 10% - 20% Referrals • Secondary Care Referral • Orthopaedic • Rheumatology • Plastics • Pain Clinic • Neurosurgery PATHWAY THREE AHP led MSK service (Possibly with GPwSI) Triage Diagnostics Treatment MSK Service 80% - 90% Referrals 10% Referrals 90%Referrals DISCHARGE Return to home page

4. General GP Information What can a Physiotherapist offer? Musculoskeletal Pathway Physiotherapy Triage Information Ortho post op timescales Return to home page How to Refer to Physiotherapy Onward referrals Physiotherapy Appointments What can an Occupational Therapist offer? OHSAS Community Rehabilitation Team (CRT) What can an Orthotist Offer? Working Health Services Patients with Long Term MSK Problems What can a Podiatrist offer? Useful Websites

5. What can an Physiotherapist offer ? N.B if red flags are identified please refer to secondary care- not AHP service. • Help with any musculoskeletal condition • Diagnosis and treatment. • Simple advice (sometimes the best treatment) • A course of treatment. • Imaging requests if appropriate • Steroid injection if appropriate • Referral on to another Health Care Professional N.B. There is a high tendency for a significant number of MSK conditions to spontaneously resolve • The success of a patient’s therapy will depend on them following the treatment plan and advice given by the therapist. It would be helpful if you could ensure that the patient understands this. • Please refer to the MSK referral criteria guidelines for further information • Return to General GP Information Return to home page

6. AHP Musculoskeletal Pathway GP REFERRAL URGENT (SOON) -Seen within 10 working days Assessment, Treatment/ Self Management Reassessment No improvement in 4 treatments 2nd Opinion within physio service/ AHP Service (Pod, GPwSI, OT etc) Diagnostics Referral received into Physiotherapy Service Click for dept details Dundee Perth & Kinross Angus Triaged By Senior Physio to mainstream or specialist therapists Discharge/ Onward referral ROUTINE – as per waiting times Self Referral Return to General GP Information Return to home page

7. How to Refer to Physiotherapy • Please encourage your patient to self refer as per local agreement • Please also give out the information leaflet on self help • Patient information leaflets are available for a variety of conditions • If you would like to give us more information please use SCI gateway (RMS) • Would you like Email advice from a senior physiotherapist? Tay-uhb.mskphysio@nhs.net • Return General GP Information • Return to home page

8. Physiotherapy Triage Informationand Urgent criteria (1) • When a patient is referred or self refers to any MSK Physiotherapy Service the referral is triaged by Senior staff. • Any referral that is highlighted as being urgent by a GP will be treated as such by the physiotherapy staff. Only after discussion with the referring clinician will any change be made to the urgency of a referral. • Urgency and whether the patient will be seen by mainstream or specialist physiotherapist will be determined by the information given on the referral form. • Triage categories have been agreed in order that those patients who would benefit from earlier intervention are offered timely assessment and treatment. • For patients referred with Orthopaedic conditions the triage categories have been agreed in partnership with local Orthopaedic Consultants and the timescales for appointments follow National Orthopaedic pathways. • AHPs have the option to triage a referral as: • Urgent – to be seen within 10 working days. • Routine – to be seen as per local departmental waiting times. • Or as per Orthopaedic post op timescales. SPINAL symptoms below will be triaged as urgent • Lumbar: Below knee pain/worsening symptoms/>6 week duration • Progressive neurological deficit. Patient acutely distressed or leg pain worse than back pain Bilateral below knee pain +/- altered sensation as indicated on body chart. • Cervical: All as per Lumbar (below elbow pain/symptoms) If information available on referral: • 1 out of 3 1.Sensory Loss* 2. Motor Weakness* 3. Reflex changes* • * In combination, in the lower limb, with a positive SLR. Immediate telephone triage (to be documented on patient referral) for all newself referrals which identify: • New onset bladder or bowel dysfunction. • Combination of previous cancer/unexplained weight loss/worsening symptoms. • Saddle anaesthesia. • Return to General GP Information • Return to home page • Forward to more urgent criteria

9. Antenatal back/pelvic pain (Consider estimated due date.) Newly diagnosed CRPS Bells Palsy: (Consider duration since onset & medical management. Most current sources suggest spontaneous resolution for most cases. Prednisilone within 72 hours treatment of choice (NHS Choices; http://cks.nice.org.uk/) POP removal ORIF Removal of metalwork at fracture site Consider site of fracture (possible impact on function) & local or general anaesthetic procedure used. Acute soft tissue injuries < 6 weeks only to be categorised as urgent/soon priority in circumstances of: Worsening symptoms. Significant impact on function/mobility/weight bearing e.g. Gastrocnemius tears. Significant trauma e.g. Whiplash injury if aforementioned spinal signs present. NB The service cannot offer urgent priority appointments for all acute soft tissueinjuries. These should be directed toward self management strategies and prioritised as routine. Recently/currently off work & inability to care for dependants. Not to be used in isolation for priority appointment but may be considered in combination with other factors. Physiotherapy Triage InformationUrgent Criteria (2) • Return to General GP Information • Return to home page • Forward to Ortho Post Op Timeframes

10. Ortho Post Op Treatment TimeframesWill be seen in physio at timescales indicated For an Orthopaedic condition/#/procedure not indicated on above list resulting in uncertainty as to treatment timescale please contact the Physiotherapy Department • Return to General GP Information • Return to home page

11. AHP Appointments • All AHP appointments are arranged in line with NHS Scotland Access Policy. • Patient focused booking allows patients to make an appointment at a suitable time. This system has shown reduced DNA rate. • We aim to have all referrals triaged within one working day of receipt. URGENT - 10 working days • Patient will be contacted by phone or letter posted within 48 hours. Please include day time contact number on any SCI gateway referrals ROUTINE - as per department waiting time • Patients who are categorised as routine will be sent a letter inviting them to phone in to arrange a suitable appointment time. An appointment will normally be offered within 4 weeks of receiving the letter. When the letter is sent will vary and is dependant on the waiting time within department the patient is to be appointed to. • Patients are informed, on the invitation letter, that if they do not respond within two weeks we will assume they do not wish to make an appointment and they will be discharged from the service. • Return to General GP Information • Return to home page

12. Onward Referrals Onward referral • Following assessment and treatment, patients will either be discharged from therapy or referred onward to another department. You will be copied into any onward referral letter. • Routine discharge letters will be sent as per local agreement • If there has been an intervention, which has not resulted in a successful outcome, or the AHP needs to convey any information to the GP this will be done by letter. • AHPs may occasionally require to contact a GP by telephone to discuss a patient’s care. • Return to General GP Information • Return to home page

13. Community Rehabilitation Team The Community Rehab Team provides treatment for patients over 16 that require rehabilitation in their own environment to promote independence and optimise function in particular activities of daily living. The team provides Physiotherapy, Occupational Therapy and is supported by AHP support workers. Reduce falls risk through • Multi-factorial assessment (Tinetti 2003; Chang et al 2004) • Addressing some of the modifiable risk factors identified by SIGN (muscle weakness; abnormality of gait/balance; foot problems; layout of home environment) Improve physical function, strength, balance and cardiovascular fitness • Using progressive exercises (Binder et al 2002; Campbell et al 1997); and gait/function re-education Urgent • Acute exacerbation of chest conditions (aim to see patient in two working days) • Sudden deterioration in physical function • Recurrent falls in last 3 months impacting on ability to remain at home • Fall related injuries • Recent hospital admission/illness now impacting on function and independence Routine • Able to meet specific rehabilitation goals following a new problem and have consented to CRT assessment following explanation. • Problems and goals amenable to Physiotherapy. • Patient/carer advice for chronic conditions that require re-assessment • Return to General GP Information • Return to home page

14. Local AHP Outpatient Depts. • Return to NHS General GP Information • Return to home page

15. Working Health Services • Is your patient self employed or do they work for a small business employing less than 250 people? • The Scottish Government has funded Working Health Services to allow people who work in small businesses to access a range of specialist health services. • Please encourage your patient to self-refer by telephoning 01382 825100 for an appointment • Return to General GP Information • Return to home page

16. What can a Podiatrist Offer? • Podiatrists are autonomous healthcare professionals who deal with the prevention, diagnosis, treatment and rehabilitation of medical and surgical conditions of the feet and lower limbs. We aim to improve the mobility, independence and quality of life for their patients This can include providing the following: • essential foot care • vascular and neurological assessment • ongoing monitoring of foot health, in particular of those with circulation problems and diabetes • wound management for a patient with diabetic ulcer • nail surgery using a local anaesthetic • biomechanical assessment leading to the prescription and manufacture of foot orthoses • Return to General GP Information • Return to home page

17. What can an Orthotist Offer? • Assessment and provision of a range of splints, braces and special footwear to aid movement, correct deformity and relieve discomfort. • Return to General GP Information • Return to home page

18. What can an Occupational Therapist Offer? • Work with people of all ages and backgrounds who are affected by accident, physical and mental illness, disability or ageing • Provide help and training in daily activities, such as bathing, dressing, eating, gardening, working and learning • Offer advice on adapting the home or workplace to meet the patients’ needs • Assess and recommend equipment, such as mobility aids, wheelchairs and artificial limbs and, if needed, advise on special devices to help around the home, school or workplace • Work with organisations to improve employees' performance • Return to General GP Information • Return to home page

19. Useful Websites • www.nhs24.com • www.nhsinform.co.uk/msk • www.chronicpainscotland.org Return to General GP Information Return to home page

20. Patients with Long Term MSK problems Re-referrals of patients with Long Term MSK problems SIGN GUIDELINES CHRONIC PAIN • Patients who have previously attended physiotherapy, without benefit, are unlikely to benefit from further physiotherapy for the same problem. However, patients who understand that they have a long term problem and are happy to engage with self management techniques, could be offered a self-management advice session from the musculoskeletal physiotherapy service. • In all cases consideration should be given to self-management strategies. In the case of chronic pain, referral to Pain Association Scotland or to the Pain Clinic may be appropriate, if not considered previously. • Return to General GP Information • Return to home page

21. Low Back Pain Pathway Suspected Cauda Equina Signs and symptoms Referral information Key Information Points MRI Referral Flowchart Other Red Flags Signs and symptoms Referral Criteria / information Referral Criteria / information Referral Criteria Further options: MDT pain clinic Patient education Class Exercise referral scheme Nerve Root Pain / Spinal Stenosis Signs and symptoms GP management advice Key Information/ Prescribing guidance Simple Low Back Pain Signs and symptoms Patient information Persistent Low Back Pain GP Advice Referral options • Return to home page • LBP Patient Information leaflets Link to you tube lumbar spine examination

22. Signs and Symptoms Suspected Cauda Equina Signs and Symptoms • Dysfunction of bladder, bowel or sexual function • sphincter weaknesses causing urinary retention and post-void residual incontinence, difficulty in initiating micturition • May be decreased anal sphincter tone with consequent faecal incontinence; • Sensory changes in saddle or peri-anal area • Gait disturbance • Weakness of the muscles of the lower extremities innervated by the compressed roots • Bilateral leg pain below the knee and weakness • Bilateral absence of ankle reflexes. • Pain may be wholly absent; the patient may complain only of lack of bladder control and of saddle anaesthesia Return to LBP Pathway Forward to Emergency Referral Information Return to home page Patient Primary Care Secondary Care

23. Emergency Referral Information Suspected CaudaEquina • Discuss with on call team Neurosurgical Unit Malignant Spinal Cord Compression Hotline for those people with history of cancer + new lumbar spine referral + gait disturbance: 07960 512277 Signs and Symptoms • History of cancer • Band like, escalating trunk pain • Can be worse lying flat/at night • Gait disturbance/vague non specific lower limb symptoms /reduced mobility • Altered sensation in non-dermatomal pattern. Return to LBP Pathway Return to home page Secondary Care Primary Care Patient

24. Red Flags part 1 Signs and Symptoms and Referral Criteria • Upper Motor Neurone lesion • Urgent referral to Neurosurgical department • Non-dermatomal sensory loss (stocking/glove) • Paraesthesia • Non myotomal muscle weakness • Hyperreflexia • Positive Lhermitte’s sign (neck flexion produces general electric shock) • Positive Hoffmans sign (flexion and sudden release of the terminal phalanx of the middle finger results in reflex flexion of all the digits) • Generalised hypertonicity or flaccidity • Positive Babinski • Aortic Aneurysm • Urgent referral to surgical team • Over 60 • Acute, sudden onset of back pain • Low back pain that is severe - doubled over in pain. • Severe abdominal pain • Continuous pain, not better with rest • Pain may radiate into the groin or leg • Pain may be accompanied by symptoms of internal bleeding, such as nausea, vomiting, rapid heart rate, cool or clammy skin, sweating, and/or shortness of breath. Primary care • Consider bloods- FBC, UE's, LFT's bone group, CRP/PV • X-rays not recommended unless thoracic osteoporotic fracture is suspected Secondary care Red Flags: NB: Index of suspicion only Discuss with Physiotherapy / Neurosurgical on call team • First acute onset age <20 or >55+ raised ESR or abnormal FBC or LFT’s • Non-mechanical pain • Thoracic pain • PMH -cancer, previous IV drug abuse, HIV, steroids, osteoporosis, TB • Unwell, weight loss >10 % body weight within 3-6 months • Widespread neurology – unilateral or bilateral lower limb weakness and/or numbness extending over several dermatomes • Pain worse at night/night sweats • Structural deformity (acquired and deteriorating, not congenital) • Trauma Forward to more red flags Return to LBP Pathway Return to home page Secondary Care Primary Care Patient

25. Red Flags part 2 Signs and Symptoms and Referral Criteria Inflammatory Spondyloarthropathy: Urgent referral to Rheumatology department • Morning stiffness & backache, or multiple joint problems (pain/stiffness/swelling) • Generally unwell • Classic Ankylosing Spondylitis posture (insidious onset, ≤40, persisting at least 3/12, associated with morning stiffness, better with exercise) • Associated skin rash, inflammatory bowel disease, eye problems (uveitis/conjunctivitis), urethritis or sacroiliac pain/tenderness • Any of the above with or without the following: • Positive C-Reactive protein (CRP),ESR, Plasma viscosity (PV) • Positive HLA B27test in conjunction with XR changes and / or positive CT of SI joints or bone scan. • Raised ESR in conjunction with positive HLA B27 test Aortic Aneurysm Urgent referral to surgical team • Over 60 • Acute, sudden onset of back pain • Low back pain that is severe - doubled over in pain. • Severe abdominal pain • Continuous pain, not better with rest • Pain may radiate into the groin or leg • Pain may be accompanied by symptoms of internal bleeding, such as nausea, vomiting, rapid heart rate, cool or clammy skin, sweating, and/or shortness of breath. Discitis/infection symptoms: Discuss with Neurosurgical on call team • Sudden onset of acute spinal pain or suspicious change in pattern, no history of trauma • Systemic signs, fever, high pulse • Night pain • All spinal movements grossly restricted by pain & spasm Return to previous page Return to LBP Pathway Return to home page Secondary Care Primary Care Patient

26. MRI Referral Flow Chart Nerve Root PianPlain film lumbar spine XR is not indicated as it does not contribute to the management of leg pain Is patient younger than 16 years Yes No Your patient may have unexpected pathology and paediatric referral is indicated Does pain radiate below the knee and a genuine straight leg raise (SLR) sign is present? (SLR test results in severe aggravation symptoms or LBP, not just hamstring tightness) Does patient have motor deficit e.g. foot drop. NB absent ankle jerk is not motor deficit No Yes Return to LBP Pathway Return to home page Forward to criteria for Acceptance GP Referrals MRI MRI not indicated No Yes Refer forurgent MRI and urgent surgical clinic review On MRI request form, write ‘urgent’ and the name of the consultant your patient has been referred to Has the patient has symptoms for more than 4 weeks? No Yes Refer for routine MRI. Surgical discussion at referrer’s discretion. MRI request forms should state the side and dermatomal location of symptoms / signs so that informed correlation with imaging findings can be made. E.g. right side sciatica, L5 dermatomal pain/numbness. No motor signs ? R L5 nerve root entrapment MRI not indicated. Continue with conservative management, as symptoms may improve spontaneously

27. Routine referral Sciatica Patients over 16 with sciatica, defined as pain radiating below the knee, showing no improvement within 4 weeks of onset, with sensory deficit or genuine positive straight leg raise. Spinal Claudication Patients with symptoms suggesting spinal claudication (stenosis). (Pain, weakness or numbness in one or both legs, present on walking, eased by sitting or bending forward, lower limb circulation normal) Urgent Referral Patients with sciatica and a developing motor deficit should be referred simultaneously for an urgent MRI scanand a surgical opinion. This should be specified on the MRI referral form so that it will be expedited and result made available for the clinic appointment. NB an absent ankle reflex in isolation is not a motor deficit Clinical conditions excluded from pathway Suspected acute cauda equina syndrome should be managed as emergency Patients with Mechanical LBP should NOT be routinely referred as most do not require or benefit from MRI scanning Criteria for Acceptance of Direct GP Referrals for Lumbar Spine MRI (local agreement) Return to LBP Pathway Return to home page

28. Signs and SymptomsSimple low back painNerve root pain • Presentation 20-55 years • Lumbosacral buttock and thigh pain • Mechanical pain • Patient well • Spinal stenosis • Referred leg pain, could be uni or bilateral • Reproduced on walking/standing • Better/disappear with sitting • May not have neuro signs • Vascular claudication should be ruled out • Unilateral leg pain worse than back pain • Radiates past knee • Numbness or Paraesthesia in dermatomal distributions • Segmental motor deficit • Limitation of SLR with production of pain • May have specific neurological symptoms incriminating single nerve root • May have hyporeflexia Return to NHS LBP Pathway Forward to GP management advice LBP/Nerve root Signs Forward to Physiotherapy referral criteria LBP/Nerve root Signs Return to home page Secondary Care Primary Care Patient

29. GP Management and Advice Low Back Pain/Leg Pain Primary Care Management of Acute Low Back Pain • Diagnostic triage: • Simple backache • Nerve root pathology • Serious spinal pathology • Rule out Red Flags • Provide reassurance, advise to stay as active as possible and to continue normal daily activities • Increase their physical activities progressively over a few days or weeks, stay at work if possible orreturn to work as soon as possible. • Address any additional yellow flag signs: • Attitudes & beliefs about back pain • Behaviour • Compensation issues • Diagnosis & treatment • Emotions • Family • Work • Do notrecommend or use bed rest as a treatment. Some patients may be confined to bed for a few days as a consequence of their pain, but this should not be considered a treatment. • Issue advice sheet, Encourage self management. • Advise that nerve root pain may take several months to settle. 90% of back pain should improve within 6 weeks. • Symptomatic measures, local ice or heat • Prescribe analgesics at regular intervals (not prn) • Self referral to Physiotherapy: should be considered for patients who have not returned to ordinary activities and work 6 weeks after onset of symptoms • NB: refer to physiotherapy earlier if • patient acutely distressed, • and/or worsening leg pain, worse than back pain Return to NHS LBP Pathway Prescribing Guidance Forward to Referral Criteria Return to home page

30. Referral Criteria and Information Nerve Root Pain and Simple Low Back Pain Direct Access Physio if For Management of continuing Chronic Low Back Pain Not settling within 6 weeks/ADL's affected Even if previous physio no benefit still refer for current episode of LBP Off work/carer Yellow flags Patient/clinician concern Onward specialist referral to Physio Lead/Advanced Physiotherapy Practitioner will be arranged if no improvement in 4-6 sessions • For longstanding chronic pain with psychosocial dominance or distress indicating a multi-disciplinary team management approach is required. • Refer to Pain Management Service • Physio Lead/APP for advice/ongoing management • APP will • Recommend further treatment • Order further investigations as appropriate • Onward referral as appropriate Between 6 and 12 week point for most patients Direct access Physio APP: if patient has: no improvement in sciatica leg pain, with failed conservative management, symptoms significantly affecting quality of life And only if the patient would consider surgery:order MRI scan (GP or APP) NB Patients with chronic symptoms unchanged for 2 years or more should not be considered for surgery If there is neuropathic pain with no neuro deficit present then delay MRI request for further 4 weeks (watchful waiting) to see if neuropathic pain will improve with appropriate medication as per neuropathic pain guidelines Pain Management Approach • Use SCI Gateway & include the following information: • Conservative management tried (and detail) • Any history of back problems or previous operations • If patient is diabetic or pregnant Discuss with Spinal Specialist If holistic pain management approach is not successful and there is a clear mechanical element to the pain (and patient is psychologically ready for an operation), consideration should be given to a referral to an Orthopaedic Spinal Surgeon if patient would consider surgery. This should be discussed with the Spinal Surgeon prior to referral. If MRI shows a significant stenosis, or a disc prolapse that could account for the patients symptoms, refer to Spinal Service for assessment If MRI shows no lesion to account for the pain Refer to Spinal Service • Use SCI Gateway & include the following information: • Conservative management tried (and detail) • Any history of back problems or previous operations • If patient is diabetic or pregnant • Include report of MRI scan, where it was performed & its correlation with presenting symptoms & signs, indicating side of pain Return to LBP Pathway Return to home page Forward to secondary care management MRI lumbar spine flowchart Adapted from Scottish Government Task and Finish Group, 2011

31. Secondary Care Management Out Patient Appointment with Spinal Service The Spinal Specialist should use a recognised assessment tool to review the patient for surgical treatment Lumbar Disc Prolapse with Uncomplicated Sciatica Lumbar Spinal Stenosis Mechanical Back Pain • For patients whose scan demonstrates Central Canal Stenosis or Lateral Recess Stenosis – consider surgical decompression with or without fusion as required. • Foraminal Stenosis or Canal Stenosis – For patients with significant symptoms of spinal claudication with positive imaging results showing Central Canal (with or without lateral recess) Stenosis, and associated Degenerative Spondylolisthesis – consider surgical decompression with or without fusion as required. • Surgery should not be routinely offered for mechanical back pain • Spinal Surgeons may offer a surgical service in very selective circumstances where a holistic pain clinic/conservative management approach has not been successful. • Implants must only be used where national audit data is being kept on longer-term outcomes, which should include patient selection and the need for further surgery • The majority of patients who are suitable to be operated on by a Spinal Specialist should have their surgery by 26 weeks after onset of pain (depending on specific clinical circumstances) • Patients with chronic symptoms unchanged for 2 years or more should not be considered for surgery Adapted from Scottish Government Task and Finish Group, 2011 Return to LBP Pathway Return to home page

32. Key Information / Prescribing Guidance Key Messages Needs a specific definition of neuropathic/neurogenic pain and recommendations on suitable medications • Low back pain is a common problem. • Simple backache: give positive messages. • Advise exercise, to be physically active and to carry on with normal activities as far as possible • Avoid opioids if possible. • At 6 weeks, 90% of patients are much improved, if not symptom-free • Red flags point to serious underlying conditions or complications • Yellow flags point to possible barriers to recovery Prescribing Guidance Prescribe analgesics at regular intervals, not when required • Start with paracetamol. • If inadequate, substitute NSAIDs and then paracetamol-weak opioid compound • Finally, consider adding a short course (3-4 days) of muscle relaxant • Avoid strong opioids if possible and never more than 2 weeks • For further information refer to:Report of CSAG Committee on back painRCGP Primary Care Management of Simple Back Pain Return to LBP Pathway Return to home page Prescribing Guidance

33. Patient Information Nerve Root Pain and Simple Low Back Pain • www.nhs24.com • www.nhsinform.co.uk/msk • www.chronicpainscotland.org • NHS Inform Back in Control • NHS Inform Back Problems • NHS Inform Back (PhysioTools) • NHS Inform Back (Video Physio) • helpline@backcare.org.uk • BackCareiphone app- free from app store • MSK app • BackCare helpline 08451302704 Return to LBP Pathway Return to home page

34. Further options Nerve Root Pain and Simple Low Back Pain Pain association groups information: Angus: Board Room, Arbroath Infirmary, 11-1pm, 3rd Monday of the month Dundee: Conference Centre, Kings cross Hospital, 2- 4pm, 3rd Monday of month Perth & Kinross: Seminar Room 5, Steele Memorial Lecture Theatre, PRI. Times vary, phone for information Phone no for information: 0800 7836059 Web: www.painassociation.com Return to LBP Pathway Return to home page

35. Persistent Low Back Pain • Lower back pain persisting over 6 months • more likely to be persistent among people who previously required time off from work because of low back pain • those who expect passive treatments to help • those who believe that back pain is harmful or disabling or fear that any movement whatever will increase their pain • people who have depression or anxiety • Consider “yellow flags” • Consider diagnosis/investigations/treatment to date • Consider compliance with any exercise programmes and/ or Physiotherapy Persistent LBP referral options Return to LBP Pathway Return to home page

36. Referral options Persistent Low Back Pain • Consider referral to LTC management classes/local authority classes/on line courses • Consider referral to secondary care (incl MDT pain clinic) where felt clinically appropriate • Pain association groups • Psychological referrals Self Help • www.nhsinform.co.uk/msk • BackCare iphone app • BackCare helpline 08451302704 • helpline@backcare.org.uk • Surgery will not be routinely offered for mechanical back pain Return to LBP Pathway Return to home page

37. Knee Pain Information General advice/ Red Flags Osteoarthritis Anterior Knee Pain (AKP) Link to You Tube Knee Examination Return to home page Meniscal Problems Bursitis Ligament Sprains MRI Criteria Patient Information Leaflets Injection advice

38. General Advice Mechanism and duration of symptoms are important to document in knee referrals; Knee arthroscopy is usually not indicated in patients > 50 years with radiographic changes of degenerative disease; Knee arthroplasty is usually not appropriate in patients with BMI > 40; Knee effusion with no history of trauma should be referred to Rheumatology; Ongoing pain and history of previous knee arthroplasty refer to Orthopaedic Department; Mechanical patellofemoral problems should have at least 6 months trial of conservative treatment before orthopaedic referral. (refer to physiotherapy) Red Flags:Indications of Possible Serious Knee Pathology (NB: some provide a warning rather than dictate a need for referral) Non mechanical pain Raised temperature at knee joint(s) Joint erythema Fever Lumps or bumps present around knee Past medical history of carcinoma Unwell – Unexplained weight loss Joint effusion with no obvious cause Joint effusions > 1 Joint Suspected fracture, dislocation or neurovascular compromise Unable to weight-bear Significant injury? (feeling of pop/snap, rapid swelling, inability to complete activity?) Suspected fracture, extensor mechanism failure?(Test - Can’t straight leg raise?) Red Flags General Advice • Return to Knee Pain Information • Return to home page Secondary Care Primary Care Patient

39. Anterior Knee Pain (AKP) Signs and Symptoms Common 16-40 years • Often no history of injury • Retropatellar ache may also lateralize to the joint lines or all over the knee • Often bilateral • Pain with stairs, hills, sitting for long time and start up pain • Pain on squatting/kneeling • Pain also associated with active patients who do jumping activities • Pseudo-mechanical symptoms (regular but transient) • Chronic presentation • Pain on patella compression or Osmond Clark test (apply an inferior glide to the patella while the patient actively contracts quads) • Weakness on static quads contraction through range • Patient otherwise well • Effusion uncommon Adolescent knee pain • Onset usually at the beginning of the growth spurt either insidiously, or with overuse (Osgood Schlatters) • Often pain eliminates the ability to do physical activity • May continue throughout adolescence AKP Referral Criteria Primary care • Analgesia, NSAIDS • Physiotherapy (+/-podiatry/ biomechanical assessment) management only • Advice on weight loss if appropriate Imaging: XR/MRI not indicated Secondary care • Not indicated - Primary Care management only AKP Patient Informationleaflet Anterior Knee Pain • Return to Knee Pain Information • Return to home page Secondary Care Primary Care Patient

40. Osteoarthritis Knee (OA) Signs and Symptoms • Commonly >50 years (previous history of knee surgery reduces age range) • Pain (particularly on moving, weight bearing or at the end of the day) • Reduced range of flexion/extension with stiffness (especially after rest, or at start of day ) • Crepitus • Hard swelling (caused by osteophytes) or Soft swelling(synovial thickening/effusion/bursitis) • Reduced walking distance/Limp/Use of walking aid/ADL OA Referral Criteria Primary care • Analgesics/NSAIDs, • Walking aid, advise patient to stay as active as possible and to continue normal daily activities, • Weight loss if appropriate, ( 1:8 failure rate for surgery with BMI over 35) • Steroid injection can be done by appropriately trained GP or Physiotherapist • Physiotherapy assessment/treatment • Imaging Weight bearing XR to confirm diagnosis or if meaningful change in management would be facilitate Secondary care • Significant persistent pain/disabling symptoms/decrease in function • Significant OA changes on XR (Tri-compartment) that is clinically relevant NB: imaging changes correlate poorly with clinical findings and pain - changes on their own should not trigger referral for a surgical opinion. • Surgical candidate :Appropriate age range/BMI • Significant sleep disturbance • Previous attempt at weight reduction and rehabilitation • All of the above despite appropriate analgaesics • Document on referral Pain duration and Severity (night pain) BMI Conservative treatment to date Use of walking aid Functional limitation XR findings Injection AdviceReturn to Knee Pain Information Return to home page OA Patient Information leaflet– OA Knee Secondary Care Primary Care Patient

41. Meniscal Problems • Signs and Symptoms • History of significant injury • Commonly 16-50 years • Feeling of a pop with twisting injury • Episodes true locking (block to full extension). • Episodes true giving way (associated with effusion, which gradually develops over 8 hours) • Worse on WB/ twisting • Localised joint line pain • PositiveMcMurray • Positive Steinman • Positive Thessaly • Asking patients to squat and/or duck-walk will frequently reproduce symptoms • NB: No test is specific and, therefore, a combination of provocative manoeuvres should be performed • Degenerative meniscal tears. Cartilage weakens and wears thin over time. • Pain • Stiffness and swelling • Catching or locking of knee • The sensation of knee "giving way" • Reduced range of motion Meniscal Problems Referral Criteria Primary care • Analgesia • Degenerate meniscal tears or acute meniscal tears with no true locking– Refer to Physiotherapy Meniscal Problems Patient Information leaflet– Meniscal problems Secondary care Locked knee - Refer to MRI protocol • Return to Knee Pain Information • Return to home page Secondary Care Primary Care Patient

42. Ligament tears/sprains Signs and Symptoms Soft Tissue Injury • Any age but commonly 16-50 Tears: • Valgus / varus stress or a twist • Feeling of a pop or a snap at injury • Rapid developing effusion • Pain • Instability/ knee giving way • Inability to complete physical activity. • If ACL or PCL usually severe trauma, with laxity on Anterior drawer and Lachman’s test Sprains: • History suggestive of valgus/varus stress • Pain on movement and palpation • Absence of effusion Ligament sprains - Referral Criteria Primary care • Mechanism of injury suggestive of ligament damage • Failure of initial PRICE treatment • Consider impact on professional or physical activity • Analgesia & NSAIDs as appropriate • Refer to physiotherapy Secondary care • Rapid haemarthrosis with knee instability Phone on call orthopaedic registrar • XR prior to referral Ligament sprains Patient Information leaflet- Ligament Sprains/Strains Return to Knee Pain Information Return to home page Secondary Care Patient Primary Care

43. Bursitis Signs and Symptoms • Swelling, tenderness, in the overlying area of the knee. • Can be associated with warmth and erythema • Usually only mildly painful. • Pain when kneeling (prepatellar bursa) or on full knee extension (Baker’s cyst) • Can cause stiffness and pain with walking. • Range of movement of the knee frequently preserved. Bursitis Referral Criteria Primary care • Rest • Analgesia & NSAIDs as appropriate • Non infected- refer to physiotherapy Secondary care • Infected- refer to orthopaedics - Phone on call orthopaedic registrar Bursitis Patient Information leaflet– Bursitis Return to Knee Pain Information Return to home page Secondary Care Primary Care Patient

44. MRI notindicated Patients under 15 or over 60 Locked knee symptoms are continuous, not momentary or intermittent a locked knee lacks at least 15 degrees of extension and cannot flex to 90 degrees (such patients need urgent orthopaedic referral with a view to arthroscopy – MRI is unnecessary and delays treatment) Pseudolocking (not to be confused with locking, this is momentary stiffness following a period of immobility – typically in obese people with patellofemoral OA) Knee dislocation or other severe acute injury (such patients are orthopaedic emergencies and should be dealt with by secondary care) Any osteoarthritis (OA) on an x-ray Obese patients with any clinical or radiographic evidence of OA (OA is very common in obese people – MRI in knees with OA often shows meniscal damage that is not treatable by arthroscopy) Any previous meniscal surgery (post-operative menisci simulate meniscal tears on MRI – direct orthopaedic clinic referral is appropriate in such patients) Active knee inflammatory arthritis, unless symptoms relate to a recent injury Anterior knee pain (usually due to patellofemoral OA, chondromalacia patellae or tendon problem which may benefit from physiotherapy) MRI indicated A knee XR must have been obtained within 6 months of MRI request Suspected meniscal tear previous injury with medial joint line tenderness and pain worsened by external rotation at 90 degrees knee flexion Or lateral joint line tenderness and pain worsened by internal rotation at 90 degrees knee flexion Instability previous injury subsequently, knee gives way during rotation or pivoting MRI Criteria(Barry Oliver Consultant Radiologist, Graeme Foubister Petros Boscainos and Richard Buckley Consultant Orthopaedic Surgeons) • Forward to MRI knee flowchart • Return to Knee Pain Information • Return to home page

45. Flowchart For Knee GP MRI Direct Access (local agreement) Is the patient aged 15-60 years? No patient > 60 will be accepted for knee MRI NO Consider Children's Orthopaedic or Paediatric clinic referral for children. OA is very common in those over 60 years – consider trial of symptomatic treatment. YES YES Is the knee locked? Is this a severe acute injury? Urgent orthopaedic referral is indicated. MRI may delay treatment NO A knee XR must have been obtained within 6 months of MRI request Is there: Any evidence of OA on x-ray? Pseudolocking? Predominantly anterior knee pain? YES OA is likely cause of symptoms. Consider symptomatic treatment or physiotherapy. NO YES Rheumatology clinic referral may be more appropriate in the absence of a relevant injury. Is there an active inflammatory arthritis and no recent injury? NO YES Has there been previous meniscal surgery? Consider Orthopaedic referral. NO YES Do clinical features indicate: instability or meniscal tear MRI referral may be beneficial to this patient NO • Return to Knee Pain Information • Return to home page Consider symptomatic treatment or physiotherapy

46. Knee Joint Injection Technique • Patient sits with knee supported in extension • Identify medial edge patella, lift up slightly by applying pressure to lateral edge. (Can also go from lateral side- Idea is to get the needle into the retropatellar pouch) • Clean area with sterets/chloroprep • Insert needle and angle laterally and slightly upwards under patella • No resistance should be felt to delivering solution • 40 mg Kenalog/5mls 1% Lidocaine or 10 mls 0.5% Chirocaine • Green or blue needle depending on size of patient • Deliver as Bolus or aspirate then inject as required • Aftercare advice: avoid undue weight bearing • 1 week, then return to mobilising and strengthening exercises • NB: Physiotherapists must comply with PGD • Return to Knee Pain Information • Return to Injection Advice • Return to home page

47. Hip Pain Information Red Flags Youtube Hip Examination Return to home page Hip joint pain/ Osteoarthritis Trochanteric Bursitis Tendinopathy Patient Information Leaflets Injection Advice

48. Hip PainRed Flags Serious Pathology Urgent referral to A & E • Suspected/known hip fracture • Violent trauma (RTA/fall from height) • Inability to WB Possible Serious Hip Pathology (NB: some provide a warning rather than dictate a need for referral to orthopaedics) • Suspected Joint infection (immediate referral) • Avascular Necrosis • Sudden/rapid deterioration causing severe disability • Constant/progressive non mechanical pain • Severe unremitting night pain • PMH cancer • Systemically unwell • Structural deformity • Gross loss of movement (mobility with severe pain) Return to Hip Pain Information Return to home page Secondary Care Primary Care Patient

49. Hip Joint Pain/Osteoarthritis (OA) Signs and Symptoms • Pain localized to the groin area and the front or side of the thigh. • Morning stiffness • Limited range of movement of the hip (Medial (internal) rotation, flexion, abduction, extension) • Pain during movement • Pain on weight-bearing • Difficulty putting on shoes/socks • Beware of knee pain as referred pain can be associated with OA hip Labral tears • Two types of hip labral tears: degenerative tears and traumatic injuries. • Degenerative labral tears can be seen in the early stages of OA • Traumatic labral tear: History of twisting on a weight bearing hip during activity common or participation in multi-directional high acceleration/deceleration sports. • Causes immediate pain in the hip • Usually located at the front of the hip joint in the groin • Pinching sensation on hip flexion , • ‘Snapping’ sensation • Limited ROM • Can be seen in association with episodes of hip dislocation or subluxation OA Hip patient information leaflet: OA Hip Forward to Hip Pain Referral Criteria Return to Hip Pain Information Return to home page Secondary Care Primary Care Patient

50. Hip Joint Pain/Osteoarthritis (OA) Hip joint pain Referral Criteria Primary care • Analgesics/NSAIDs, Analgesia taken regularly can aid comfort with pain/ reduced ROM • Walking aid, advise patient to stay as active as possible and to continue normal daily activities • Weight loss advice if appropriate • AP pelvis X-Ray beneficial to aid diagnosis • Ensure pain not referred from lumbar spine pathologies • Physiotherapy assessment/treatment Secondary care • Disabling symptoms, • Gross OA changes on XR, • Surgical candidate (BMI over 35 consider weight loss strategies) • Document on referral • Duration of symptoms and any cause of onset • Pain spread and severity (constant/ intermittent/ night pain) • Conservative treatment to date • Use of walking aid • Functional limitation • XR findings • Restriction of internal rotation • BMI OA Hip patient information leaflet: OA HipReturn to Signs and Symptoms Return to Hip Pain Information Return to home page Secondary Care Primary Care Patient