Appendix 1
Tier II Clinical Assessment Service
Examples amongst many, of appropriate referral include patients with:
Knees






OA knee with pain unacceptable despite medication and/or physiotherapy
Any persistent pain possibly from meniscal, osteochondral or ligament injury
Persistent knee swelling / bursitis of unknown cause
Instability of knee or patella
Anterior knee pain unresolved with physiotherapy
Patella tendon symptoms
Shoulders




Persistent shoulder pain despite physiotherapy
Persistent reduced range of movement despite physiotherapy
Instability of shoulder
Failure of shoulder injection in primary care
Upper Limb





De Quervains Tenosynovitis
Non-specific chronic wrist pain
OA of elbow/wrist/hands
Tennis or golf elbow, not responding to injection/physiotherapy
Referred pain from neck
Neck
 Unresolved neck pain despite physiotherapy input
 Referred symptoms to upper limb
 Thoracic outlet syndrome
Spine






Thoracic spine dysfunction affecting trunk or upper limb
Low back pain not resolving with primary care management
Suspected lumbar disc prolapsed with leg pain
Lumbar canal stenosis
Back pain in young athletes
Sacro-iliac joint dysfunction
Hip & Groin





OA of hip non-surgical management
Groin pain for diagnosis, eg sportsman’s hernia, hip pathology
Trochanteric bursitis
Femoroacetabular dysplasia/impingement
Sportsman’s hernia
Foot & Ankle







Achilles pain
Heel pain
Ankle instability/persistent pain
Midfoot pain
Forefoot pain
OA of forefoot joint for injection
Shin pain
NB. The above are examples and not comprehensive
MSK TIER II Exclusions
Direct referral to secondary care by GP is appropriate for:
Red Flags – Urgent
1.
 Suspicion of systematic inflammatory disease requiring medical management, e.g. morning stiffness
present for > 30 minutes or more than 6/52
o

Suspicion of serious pathology (malignancy, infection), i.e. general malaise, weight loss, night
sweats, loss of appetite
o

Refer directly to neurosurgery/orthopaedics
Suspicion of recent fracture requiring intervention
o
2.
Refer directly to secondary care
Signs of cord compression/cauda equina syndrome, ie bilateral leg pain, bladder/bowel frequency or
retention, saddle anaesthesia, gait disturbance, pins & needles, numbness, or worsening
neurological symptoms.
o

Refer directly to rheumatology
Refer directly to orthopaedics
Post-Surgical Problems
Where a patient has recently had an operation and has developed a complication of that surgery, they
should be referred back to the surgery/department that performed the surgery. This should include:
 Immediate post-operative complications
 Later complications, e.g. prosthesis failure
 Trauma to prosthetic joint
3.
Acute Trauma
Any acute MSK trauma should be referred to A & E for fracture clinic, e.g. suspicion of fracture or
dislocation or major soft tissue rupture (muscle tendon or ligament).
4. Previously assessed patient requests surgery
Where a patient has been previously assessed as suitable for surgery, either in MSK Tier2 or secondary
care, but has deferred this, on re-presentation may be referred direct
5.
Previously assessed MSK Tier2 patient
Where a patient has previously been assessed in MSK Tier 2 and the discharge letter has suggested
referral direct to secondary care if re-presents
6.
Children
MSK Tier II does not see children. Any under-16 MSK problems should be referred to secondary care
(paediatrics) or via A & E if acute
Your local contact in SW Essex - Cara Finnigan
cara.finnigan@swessex.nhs.uk
Referral Form – NHS South West Essex MSK Service
Appendix 2
GP REFERRAL TO MSK TIER II
NOTE:
Use this service for more complex MSK patients who you think might need referring to
secondary care or require investigation, ie specialist opinion
Waiting time for MSK Tier II is typically less than 2 weeks
Date of Referral
NHS Number
Name
Previous Name
DOB:
Age
Address
Gender Ethnic Code
Telephone
Home:
Work:
Mobile:
Can a message be left at the above number?
Name of Patient’s GP
Surgery
Telephone.
Surgery Name &
Address
Surgery Fax
Practice Code
Hard of hearing?
Is the patient eligible
for hospital transport?
Interpreter required?
Please specify language
Does the patient require
hospital transport?
(eligible patients only)
I have attached GP Referral letter (GP referral should be comprehensive enough to
allow an informed paper triage decision to be made): YES / NO
If no, GP should complete following sections:
Reason for referral:
History of symptoms and interventions / treatments tried to date (eg previous medications
tried):
Has patient had previous physiotherapy: If yes, what was the outcome:
Examination findings:
Treatments tried to date:
What does the patient expect from this referral, eg diagnosis, symptom control, investigation,
surgery?
Are there any particular issues you as the referrer would like addressing?
Any other issues or comments, eg significant issues that may impact on care, eg only carer?
Investigations to date and results: (Please include copies of results):
Last Consultation:
Medical History:
Current Medication:
Allergies:
Please complete form and send to Tier II with / without referral letter
i) attach to URBN, or
ii) e-mail to swe-pct.TierII-MSK@nhs.net, or
iii) fax to 01268 531227