Musculoskeletal Decision Making Tool
This tool is currently in
development and work is
underway to refine and enhance
flow and ease user interaction
Musculoskeletal Decision Making Tool
MSK Pathway
General GP
Information about
Allied Health
Professionals
General Injection
Advice
Patient
Information
Leaflets
Contact us
Useful websites
Click over affected area
for guidelines / advice /
referral guidance
Alternatively click on
body area below
Cervical spine
Thoracic Spine
Shoulder
Elbow
Wrist and Hand
Lumbar Spine
Hip
Knee
Foot and ankle
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
Key
MSK PATHWAY – DRAFT
National MSK programme (Blue)
NHS Tayside programme (Yellow)
PATHWAY ONE
Self
Management
and Advice
Simple MSK Problem *
NHS 24
PATHWAY TWO
10% - 20% Referrals
PATIENT
GP
Red Flags
Severe Pain, Significantly
Decreased Function OR
Clear Secondary Care
Referral
(refer to MSK guidelines)
Secondary
Care Referral
PATHWAY THREE
80% - 90% Referrals
MSK
Service
AHP led MSK service
(Possibly with GPwSI)
Triage
Diagnostics
Treatment
90%
10% Referrals





Orthopaedic
Rheumatology
Plastics
Pain Clinic
Neurosurgery
Referrals
DISCHARGE
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General GP Information
What can a
Physiotherapist
offer?
How to Refer to
Physiotherapy
What can an
Occupational
Therapist offer?
What can an
Orthotist
Offer?
What can a
Podiatrist
offer?
Musculoskeletal
Pathway
Physiotherapy Triage
Information
Onward referrals
Physiotherapy
Appointments
Ortho post op timescales
OHSAS
Working Health
Services
Useful Websites
Community
Rehabilitation
Team (CRT)
Patients with Long
Term MSK
Problems
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What can an Physiotherapist offer ?
N.B if red flags are identified please refer to secondary carenot 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
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AHP Musculoskeletal Pathway
GP
REFERRAL
Referral received
into Physiotherapy
Service
Click for dept details
Dundee
Perth & Kinross
Angus
Triaged By
Senior
Physio to
mainstream
or specialist
therapists
URGENT
(SOON) Seen
within 10
working
days
Assessment,
Treatment/ Self
Management
Reassessment
No improvement
in 4 treatments
ROUTINE
– as per
waiting
times
2nd Opinion
within physio
service/ AHP
Service (Pod,
GPwSI, OT etc)
Discharge/
Onward
referral
Self Referral
Diagnostics
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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
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Physiotherapy Triage Information
and 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 new self referrals which identify:
New onset bladder or bowel dysfunction.
Combination of previous cancer/unexplained weight loss/worsening symptoms.
Saddle anaesthesia.
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Forward to more urgent criteria
Physiotherapy Triage Information
Urgent Criteria (2)
•
•
•
•
•
•
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
tissue injuries. 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.
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Forward to Ortho Post Op Timeframes
Ortho Post Op Treatment Timeframes
Will be seen in physio at timescales indicated
Shoulder
Knee
Replacement for #
3 weeks
TKR
2 weeks
Bankhart repair
6 weeks
ACL Reconstruction
10 Days
Slap repair
3 weeks
Arthroscopy
2 weeks
Weaver dunn
6 weeks
Dislocation
10 days
Rot cuff repair - minor (Arthroscopic)
4 weeks (2 weeks)
Hip
Rot cuff repair - major (Arthroscopic)
patch repair
6 weeks (4 weeks)
8 weeks
Bilateral THR/BHR
2 weeks
Decompression - Arthroscopic
2 weeks
Arthroscopy (depends on op)
10 days – 6 weeks
Decompression - open
3 weeks
MUA
ASAP
Fractures- general
Ankle
Replacement
6 weeks
Post op TA repair
2 weeks post ref
Elbow
10 days
Spine
Wrist – CRPS
ASAP
Microdiscectomy
6 weeks
# Femur – IM nail
10 days
Laminectomy
6 weeks
# Tibia – IM nail
3 weeks
For an Orthopaedic condition/#/procedure not indicated on
above list resulting in uncertainty as to treatment timescale
please contact the Physiotherapy Department
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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.
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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.
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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
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Local AHP Outpatient Depts.
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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
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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
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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.
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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
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Useful Websites
• www.nhs24.com
• www.nhsinform.co.uk/msk
• www.chronicpainscotland.org
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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 selfmanagement strategies. In the case of chronic pain,
referral to Pain Association Scotland or to the Pain Clinic
may be appropriate, if not considered previously.
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Low Back Pain Pathway
Suspected
Cauda Equina
Signs and
symptoms
Referral
information
Other
Red Flags
Signs and
symptoms
Referral
Criteria /
information
Nerve
Root Pain /
Spinal Stenosis
Signs and
symptoms
Signs and
symptoms
Persistent Low
Back Pain
GP Advice
Link to you tube lumbar spine examination
Referral
Criteria /
information
MRI Referral
Flowchart
Referral Criteria
GP management
advice
Simple Low
Back Pain
Key Information
Points
Key Information/
Prescribing
guidance
Further options:
MDT pain clinic
Patient education
Class
Exercise referral
scheme
Patient
information
Referral
options
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LBP Patient Information leaflets
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
Patient
Primary Care
Secondary Care
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Emergency Referral Information
Suspected Cauda Equina
• 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.
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Patient
Primary Care
Secondary Care
Red Flags part 1 Signs and Symptoms and Referral Criteria
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
Patient
Primary Care
Secondary Care
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.
Forward to more red flags
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Red Flags part 2 Signs and Symptoms and Referral Criteria
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
Patient
Primary Care
Secondary Care
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
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MRI Referral Flow Chart Nerve Root Pian
Plain film lumbar spine XR is not indicated as it does not contribute to the management of leg pain
Yes
No
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)
No
Does patient have motor deficit e.g. foot drop.
NB absent ankle jerk is not motor deficit
Yes
MRI not indicated
No
Has the patient has symptoms for more than 4
weeks?
No
Your patient may have unexpected pathology
and paediatric referral is indicated
Yes
Refer for urgent MRI and urgent surgical clinic
review
On MRI request form, write ‘urgent’ and the name
of the consultant your patient has been referred to
Yes
MRI not indicated. Continue with conservative
management, as symptoms may improve
spontaneously
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
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Forward to criteria for Acceptance GP Referrals MRI
Is patient younger than 16 years
Criteria for Acceptance of Direct GP Referrals
for Lumbar Spine MRI (local agreement)
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 scan
and 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
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Signs and Symptoms
Simple low back pain
Nerve 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
Patient
Primary Care
Secondary Care
• 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
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Forward to GP management advice LBP/Nerve root Signs
Forward to Physiotherapy referral criteria LBP/Nerve root Signs
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GP Management and Advice
Low Back Pain/Leg Pain
Primary Care Management of Acute Low Back Pain
•
•
•
•
Diagnostic triage:
–
–
–
–
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
or return to work as soon as possible.
Address any additional yellow flag signs:
–
–
–
–
–
–
–
•
•
•
•
•
•
•
Simple backache
Nerve root pathology
Serious spinal pathology
Rule out Red Flags
Attitudes & beliefs about back pain
Behaviour
Compensation issues
Diagnosis & treatment
Emotions
Family
Work
Do not recommend 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
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NB: refer to physiotherapy earlier if
Prescribing Guidance
– patient acutely distressed,
Forward to Referral Criteria
– and/or worsening leg pain, worse than back pain
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Referral Criteria and Information Nerve Root Pain and Simple Low Back Pain
Direct Access Physio if
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 Management of continuing
Chronic Low Back Pain
• 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
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
Between 6
and 12 week
point for
most
patients
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 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
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.
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
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Forward to secondary care management
MRI lumbar spine flowchart
Adapted from Scottish Government Task and Finish Group, 2011
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
•
•
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
Lumbar Spinal Stenosis
•
•
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.
Mechanical Back Pain
• 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
Adapted from Scottish Government Task and Finish Group, 2011
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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 pain
RCGP Primary Care Management of Simple Back Pain
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Prescribing Guidance
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
• BackCare iphone app- free from app store
• MSK app
• BackCare helpline 08451302704
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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, 24pm, 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
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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
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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
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Knee Pain Information
Osteoarthritis
General
advice/
Red Flags
Anterior Knee
Pain (AKP)
Bursitis
Meniscal
Problems
Ligament
Sprains
MRI Criteria
Patient
Information
Leaflets
Injection
advice
Link to You Tube Knee Examination
Return to home page
Red Flags
General Advice
Red Flags: Indications of Possible
General Advice
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?)
Patient
Primary Care
Secondary Care
•
•
•
•
•
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)
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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 Information leaflet Anterior Knee Pain
Patient
Primary Care
Secondary Care
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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)
Conservative treatment to date
Functional limitation
BMI
Use of walking aid
XR findings
Injection Advice
OA Patient Information leaflet– OA Knee
Patient
Primary Care
Secondary Care
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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
Positive McMurray
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
Secondary care
Locked knee - Refer to MRI protocol
Meniscal Problems Patient Information leaflet– Meniscal problems
Patient
Primary Care
Secondary Care
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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
Patient
Primary Care
Secondary Care
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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
Patient
Primary Care
Secondary Care
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MRI Criteria
(Barry Oliver Consultant Radiologist, Graeme Foubister Petros Boscainos and Richard Buckley Consultant Orthopaedic
Surgeons)
•
•
MRI not indicated
MRI indicated
Patients under 15 or over 60
Locked knee
•
A knee XR must have been obtained
within 6 months of MRI request
•
Suspected meniscal tear
–
–
–
•
•
(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
–
•
(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
–
–
(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
–
•
•
previous injury with
Pseudolocking
–
•
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)
(usually due to patellofemoral OA, chondromalacia patellae or
tendon problem which may benefit from physiotherapy)
Or
–
•
medial joint line tenderness and pain
worsened by external rotation at 90
degrees knee flexion
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
Forward to MRI knee flowchart
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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
YES
Is the knee locked?
Is this a severe acute injury?
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
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?
NO
YES
OA is likely cause of symptoms.
Consider symptomatic treatment or
physiotherapy.
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
Has there been previous meniscal
surgery?
NO
Do clinical features indicate:
instability or meniscal tear
YES
YES
Consider Orthopaedic referral.
MRI referral may be beneficial to this patient
NO
Consider symptomatic treatment or physiotherapy
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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
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Hip Pain Information
Red Flags
Hip joint pain/
Osteoarthritis
Trochanteric
Bursitis
Patient
Information
Leaflets
Tendinopathy
Injection Advice
Youtube Hip Examination
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Hip Pain Red 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)
Patient
Primary Care
Secondary Care
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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
Patient
Primary Care
Secondary Care
Forward to Hip Pain Referral Criteria
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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 Hip
Patient
Primary Care
Secondary Care
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Trochanteric Bursitis
Signs and Symptoms
• Pain lateral aspect hip on walking
• Inability or difficulty lying in comfort on the affected side.
• Tenderness on palpation of greater trochanter
• Chronic nature most common
• Rarely presents with swelling/warmth or erythema
• ?Tight Ilio Tibial Band (Obers manoeuvre)
• Self limiting condition, However a small but likely significant sub-population appear to continue to
have ongoing difficulties despite management. Attests to stubborn nature of condition
Trochanteric Bursitis Referral Criteria
Primary care
•
•
•
•
Should be managed in primary care only
Analgesia & NSAIDs as appropriate
Physiotherapy
Steroid injection
Secondary care
•
Not required
Trochanteric Bursitis Patient Information leaflet– Trochanteric Bursitis
Patient
Primary Care
Secondary Care
Injection advice
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Tendinopathy
Signs and Symptoms
• Pain on origin or proximal few centimetres of major tendons
• Common adductors into groin that can radiate down the leg
• Common flexors arising anteriorly
• Common hamstring origin deep into buttocks off tuberosities
• Pain on resisted movements at tendon origin
• Difficulty in running especially sprinting or changing direction.
• Injury suggestive of muscle/tendon injury
Beware of other pathologies such as
• Inguinal hernia
• Femoral hernia
• Hip pathology (OA/Labral tear)
• Pain due to tendinopathy is usually worse during and after activity, and the tendon and joint area can become stiffer
the following day as swelling impinges on the movement of the tendon. Recurrence of injury in the damaged region
of tendon is common.
Tendinopathy Referral Criteria
Primary care
• Eccentric loading exercises currently advocated.
• Analgesia & NSAIDs as appropriate
• Steroid injection
• Physiotherapy referral: Patients who fail to respond to 10-14 days relative rest/avoidance of aggravating exercise
coupled with appropriate analgesia
• Chronic presentation: The potential for chronicity is high as well as resistance to treatment.
.
Secondary care
Rarely needed
Tendinopathy Patient Information leaflet
Patient
Primary Care
Secondary Care
Injection advice
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Injection Advice
Tendinopathies
•
Identify origin of tendon
Adductor
•
Patient lies supine with leg slightly abducted and
laterally rotated
Hamstring
•
Patient lies on unaffected side with upper leg
flexed
Trochanteric Bursa
• Patient lies on unaffected side
• Identify tender area over greater
trochanter
• Clean area with sterets/chloroprep
• Insert needle perpendicularly at centre of
tender area and touch bone of greater
trochanter
• 40 mg Kenalog/5mls 1% Lidocaine or 10
mls 0.5% Chirocaine
• Green or blue needle depending on size
of patient
• Deliver as bolus when no resistance felt
•
•
•
•
•
•
40 mg Kenalog/2 mls lidocaine
Green needle
Clean area with sterets/chloroprep
Insert needle into mid point of tendon and
angle upwards towards bone
Pepper solution into teno-osseous junction of
tendon
Aftercare advice: avoid overuse 1 week then
gradually return to stretching and strengthening
programme and normal activity
NB: Physiotherapists must comply with PGD
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Wrist and Hand Pain Information
Carpal
Tunnel
Syndrome
De
Quervain’s
Cubital tunnel
syndrome
Ganglion
Red flags
Trigger
finger/
thumb
OA CMC
joint
Dupuytren’s
Non
Specific
hand pain
Patient Information
Leaflets
Youtube Wrist & Hand examination
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Red Flags Wrist and Hand
Immediate referral to Secondary Care
•
•
•
•
Sepsis/infection
Fracture
Tendon rupture
Acute ischaemia (not Raynaud’s)
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Patient
Primary Care
Secondary Care
Carpal Tunnel Syndrome (CTS)
Signs and Symptoms (Median Nerve entrapment)
Tingling and numbness in lateral (radial) 3 1/2 digits- median nerve distribution
May be associated with hand/ wrist/ forearm pain
Dropping items/clumsiness/weakness of pinch grip
+/- Weakness in abductor pollicis brevis, +/- Wasting in abductor pollicis brevis
Wake up at night & relieved with movement for 15-20 minutes
Positive Tinel’s: (i.e. produces symptoms)
Positive Phalen’s: (i.e. produces symptoms)
CTS Referral Criteria
Primary care
•
•
•
•
•
Exclude cervical radiculopathy
Wrist/ night splints - can be bought from Boots/Allardyce/PhysioMed (cock up splint) or supplied by orthotics
May resolve or significantly improve in up to 49% of cases (Padua 2001).
Physiotherapy referral
May respond to steroid injection (by appropriately trained practitioner)
Secondary care
•
•
•
If symptoms persistent, severe, especially if associated with weakness / muscle wasting:
Refer for nerve conduction studies prior to secondary care referral for surgical decompression (hand service)
Include the following information:
–
–
–
–
–
–
–
•
Duration of symptoms
Conservative management tried (e.g. any relief through splintage?)
Any history of neck problems
If patient is diabetic, pregnant or has a thyroid disorder
If symptoms are unilateral or bilateral
If motor weakness is present
Results of Nerve Conduction Study should be attached
CTS Patient Information leaflet– Carpal Tunnel
Patient
Primary Care
Secondary Care
Forward to referral criteria
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Cubital Tunnel Syndrome
Signs and Symptoms (ulnar nerve entrapment)
•
•
•
•
•
•
•
Pain, tingling and numbness in ulnar 1 1/2 digits (small and ring finger)
Can be provoked by leaning on elbow or keeping elbow bent (e.g. on telephone)
+/-Weakness in thumb and finger adduction
+/-Wasting in hypothenar eminence, interossei
Wake up at night & relieved with movement for 15-20 minutes
Dropping items
Positive Tinel’s medial elbow (May be positive anywhere along the course of the peripheral nerve that is
compromised)
Cubital tunnel syndrome Referral Criteria
Primary care
•
•
Advise avoidance or modification any provocative activity where appropriate .e.g, wear headset for using
telephone; avoid leaning on elbows or wear protective pads. Advise sleeping with arms straight if
possible. Resting night splint (towel splint)/possibly referral to Occupational therapy for bespoke elbow
extension splint..
Physiotherapy referral
Secondary care referral
•
•
•
If symptoms persistent, severe, especially if associated with weakness / muscle wasting:
Refer for nerve conduction studies before referral (hand service)
Include the following information:
–
–
–
–
–
–
Duration of symptoms and any cause of onset
Conservative management tried (e.g. any relief through activity avoidance?)
Any history of neck problems
If symptoms are unilateral or bilateral
If any motor weakness is present
Results of Nerve Conduction Study should be attached
Cubital tunnel syndrome Patient Information leaflet– Cubital Tunnel
Patient
Primary Care
Secondary Care
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Trigger Finger/Thumb
Signs and Symptoms
• Typical nodule at base of thumb or finger
• Wake up with flexed finger or thumb which can be straightened with a click
• Triggering or locking
• Pain base finger/thumb
• Progresses to triggering/locking on flexion activity
• HOWEVER - Spontaneous recovery may occur in up to 29% of patients
Trigger finger Referral Criteria
Primary care
• Modification of activity to avoid pressure on this area (e.g. adjust grip)
• Analgesia & NSAIDs as appropriate
• Refer to Hand Therapist for splint
• Steroid injection into flexor tendon sheath usually successful (70%, less if diabetic)
– Can be done by appropriately trained practitioner
– May be repeated once if initial injection gives only temporary relief
Secondary care
• Refer to hand service for release trigger finger/thumb if failure to respond to first line
treatment
Trigger Finger Patient Information Leaflet: Trigger Finger
Patient
Primary Care
Secondary Care
Injection Advice
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OA CMC joint
Signs and Symptoms
•
Pain at base of thumb on movement of CMC joint
•
Reduced range of movement (abduction and extension)
•
Pain on grinding CMC joint
OA CMC joint Referral Criteria
Primary care
•
Non steroidal anti-inflammatory drugs/analgesia
•
Modify activity/ Consider hand therapy referral
•
Splint – (wrap around thumb splint) can be bought from Boots/Allardyce/PhysioMed
•
Hand therapy to aid with pain relief/ ROM
•
Steroid injection can be done by appropriately trained GP/Physio
Secondary care
Consider referring for opinion on surgery if
•
Gross OA changes on XR and symptoms increase despite conservative treatment
•
Significant problem with function
•
Refer to hand service
•
Include the following information:
–
–
–
–
–
–
Duration of symptoms
Conservative management tried (e.g. any relief through activity avoidance/ splintage/ physiotherapy/ steroid injection?)
Movement loss
Functional limitations
Pain severity (constant/ intermittent/ waking at night)
XR findings
OA CMC joint Patient Information leaflet OA CMC joint
Patient
Primary Care
Secondary Care
Injection Advice
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De Quervain’s
Signs and Symptoms
•
•
•
•
•
Pain, tenderness, and swelling over the radial aspect of the wrist
Maybe associated with ganglion
Pain on extension/abduction of thumb, may be associated with crepitus on movement
Difficulty lifting/gripping
Positive Finklestein’s test (test by wrapping patient’s fingers around thumb then pull wrist into ulnar
deviation)
De Quervain’s Referral Criteria
Primary care
•
Conservative management:
•
Analgesia & NSAIDs as appropriate
•
Splints (wrap around thumb splint) can be bought from Boots/Allardyce/PhysioMed
•
Steroid injection into 1st dorsal compartment can be done by appropriately trained GP/Physiotherapist
•
Refer to physiotherapy
Secondary care
•
Failure to respond to injection/conservative treatment
•
Include the following information:
–
–
–
–
–
–
Duration of symptoms and any cause of onset
Conservative management tried (e.g. any relief through activity avoidance/ splintage/ physiotherapy/ steroid injection?)
Movement loss
Functional limitations
Pain severity (constant/ intermittent/ waking at night)
Any associated crepitus on thumb movements/ ganglion
De Quervain’s Patient Information leaflet– De Quervain's
Patient
Primary Care
Secondary Care
Injection advice
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Ganglion
Signs and Symptoms
•
Harmless and can safely be left alone
•
Often there are no symptoms other than noticeable cystic swelling.
•
Occasionally can cause pain and limited joint movement.
Ganglion Referral Criteria
•
Common
•
If it is not painful, no treatment is required.
•
Analgesia as appropriate if painful- simple wrist wrap around splints may help if appropriate (Allardyce/ Boots/Physiomed)
•
About 50 % disappear without any treatment
•
Aspiration (50% recurrence) Do not repeat aspiration if ganglion recurs
•
Concern about cosmetic appearance is not an indication for referral.
Further information to consider and discuss with patient prior to secondary care referral
•
Dorsal Ganglion cyst. Typically occurs in young adults and often disappears without treatment. Draining it can reduce the swelling
but it often returns. Risk of recurrence after surgery around 10%, problems post op include persistent pain, loss of wrist movement
and painful trapping of nerve branches in the scar.
•
Volar Ganglion cyst. May occur in young adults, but also seen in association with arthritis in older individuals. Aspiration may be
useful, but care needed as the cyst is often close to radial artery. Risk of recurrence after surgery is around 30%, problems post op
include persistent pain, loss of wrist movement and trapping of nerve branches in the scar. For these reasons, many surgeons
advise against operation for these cysts.
•
Ganglion cyst at the base of volar surface finger (Flexor tendon sheath). Typically occurs in young adults, causing pain when
gripping and feeling like a dried pea sitting on the tendon sheath at the base of the finger. Persistent cysts can be removed surgically
- risk of recurrence is small.
•
Mucous cyst. Usually in middle-aged or older people, associated with wearing out of DIP joint. Pressure from the cyst may cause a
furrow in the fingernail. Occasionally the cyst fluid leaks through the thin overlying skin from time to time. Risk of recurrence post op
around 10%, problems after surgery include infection, stiffness and pain from the worn out joint.
Ganglion Patient Information leaflet – Ganglia
Patient
Primary Care
Secondary Care
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Dupuytren’s Contracture
Signs and Symptoms
•
Common
•
Usually arises in middle age or later
•
More common in men than women.
•
Characterised by cords and nodules in palmar aponeurosis
•
Finger flexion develops over months/years
•
Nodules over back of the PIP joints (Garrod's pads)
•
Not usually painful
Dupuytren’s Contracture Referral Criteria
Primary care
•
No cure.
•
Palmar nodule only: no active treatment required
Secondary care
•
If patient can get hand flat on the table top there is no indication for referral
•
If fixed contracture 15° at PIP joint, or 15-30 ° MCP joint refer for surgery (either Plastic surgery or
Orthopaedics)
•
Xiapex (collagenase injections) or needle fasciotomy are only indicated for similar levels of
contracture
Dupuytren’s Contracture Information leaflet– Dupuytren's
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Patient
Primary Care
Secondary Care
De Quervain's
•
Injection Advice
•
•
•
•
•
Rest patient’s hand on edge of pillow so it lies in slight ulnar
deviation
Identify gap between APL and EPB
Clean area with sterets/chloroprep
Blue/orange needle
Insert needle into gap between the two tendons
Inject as bolus
•
Up to 40 mg Kenalog/2 ml lidocaine
Trigger finger/thumb
•
•
•
•
•
Patient places palm up, hand supported
Identify nodule at A1 pulley
Clean area with sterets/chloroprep
Insert needle approx 45°distally or proximally into nodule
Avoid injecting into tendon by withdrawing needle slightly until no
resistance felt to delivering solution
•
Up to 40 mg Kenalog/1ml Lidocaine into nodule or
flexor sheath
Orange or blue needle
•
•
Aftercare advice: relative rest 2 weeks. i.e. Avoid strong
gripping, heavy lifting
•
NB Physiotherapists must comply with PGD
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Injection Advice OA CMC joint
OA CMC joint
•
•
•
Patient rests hand in mid position (thumb up)
Apply traction to open up joint space
Identify gap of joint space at apex of snuff box
•
Clean area with sterets/chloroprep
•
•
•
Blue/orange needle
Insert needle perpendicularly into gap
Inject as bolus
•
Up to 40 mg Kenalog/1-2 ml lidocaine
•
Aftercare advice: relative rest 2 weeks i.e.
Avoid strong gripping, heavy lifting
•
NB Physiotherapists must comply with PGD
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Elbow pain Information
Tennis/Golfers
Elbow
Post traumatic
elbow stiffness
Injection Advice
Patient
Information
Leaflets
Youtube Elbow examination
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Tennis/Golfers elbow
Signs and Symptoms
Tennis
•
Recurring pain on the lateral aspect elbow; occasionally, pain radiates down the arm toward the wrist.
•
Localised tenderness extensor origin
•
Increased pain on wrist dorsiflexion
•
Pain caused by lifting or bending the arm or grasping light objects.
Golfers
•
Recurring pain on the medial aspect elbow; occasionally, pain radiates down the arm toward the wrist.
•
Localised tenderness flexor origin
•
Increased pain on wrist palmar flexion
•
Pain caused by lifting or bending the arm or grasping light objects.
Both Tennis/Golfers Elbow
•
Difficulty extending or flexing the forearm fully
•
Benign Self limiting conditions: Pain typically lasts for 6 to 12 weeks; the discomfort can continue for as little as 3 weeks or
as long as several years.
Tennis/Golfers Elbow Referral Criteria
Primary care
•
Advice / reassurance / Analgesia & NSAIDs as appropriate
•
Benign self limiting condition
•
Modify loading
•
Symptomatic measures (steroid injection / physio / splints)
•
Epicondylitis clasp can be bought from Boots/ Allardyce/PhysioMed
•
Eccentric loading exercises advocated- refer Physiotherapy
Secondary care
•
Surgery if failure to respond to physiotherapy and at least 2 steroid injections
•
Information to include when referring
–
–
–
Duration of symptoms
Indicate site/spread of pain and if constant or intermittent, and/or waking at night
Include treatment to date (injections/ physiotherapy)
Tennis/Golfers elbow Patient Information leaflet–
Tennis Elbow
Patient
Primary Care
Golfers Elbow
Secondary Care
Injection Advice
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Post Traumatic Elbow Stiffness
Signs and Symptoms
•
Common
•
Usually improves with time and use
•
Functional arc usually achieved 30-130º extension/ flexion
Post traumatic elbow stiffness Referral Criteria
Primary care
•
Reassure and advise to mobilise (active movements only, no passive stretching)
•
Analgesia & NSAIDs as appropriate
•
Refer to physiotherapy
Secondary care
•
If significant stiffness (greater than 45º loss of extension or 115º flexion or less) and functional
problem with no improvement after 6 months
•
Refer for consideration of surgical release
•
XR prior to referral
•
Information to include when referring
–
–
–
–
–
Duration of symptoms and any cause of onset
Indicate site/ spread of pain and if pain constant or intermittent, and/or waking at night
Indicate ROM and any crepitus on movement
Include treatment to date
XR results/Dominance
Post traumatic elbow stiffness Patient Information leaflet – General Elbow Stiffness
Patient
Primary Care
Secondary Care
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Injection Advice
Tennis elbow - common extensor origin
•
•
•
•
Lateral side right arm
•
Patient sits with forearm supported 90° elbow flexion and
supinated
Identify lateral epicondyle then move anteriorly on to facet
Clean area with sterets/chloroprep
Insert needle in line with cubital crease perpendicular to
facet to touch bone
Pepper solution into tendon insertion
Golfer’s Elbow - common flexor origin
•
•
•
•
•
Medial side left arm
Patient sits with forearm extended
Identify facet lying anteriorly on medial epicondyle
Clean area with sterets/chloroprep
Insert needle perpendicular to facet and touch bone
Pepper solution into tendon insertion
Up to 40 mg Kenalog/2 ml Lidocaine into common flexor
or extensor origin
Blue or orange needle
Peppering technique
Aftercare: relative rest for a week, then stretching and
strengthening exercises
• NB Physiotherapists must comply with PGD
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Cervical Spine, Shoulder & Arm Pain
Information
Red Flags
Shoulder
Impingement
Red Flags
Cervical Spine
Adhesive
capsulitis
Rotator cuff
tears
Instability/
Recurrent dislocation
Neck/Arm Pain
Patient Information
Leaflets Cervical Spine
Patient Information
Leaflets Shoulder
You tube Shoulder Assessment
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Red Flags Shoulder
Possible Serious Shoulder Pathology (NB: some provide a warning rather
than dictate a need for referral to orthopaedics)
•
•
•
•
Unexplained soft tissue mass/swelling
Constant/progressive non mechanical pain
Severe unremitting night pain
PMH cancer
–
•
Erythema/fever/systemically unwell
–
•
•
•
•
tumours: 7% of bony metastases occur in the proximal humerus
Septic arthritis: rare in the shoulder (less than 0.01%)
Inflammatory arthropathy: e.g. rheumatoid arthritis, gout and psoriatic arthropathy.
Consider polymyalgia rheumatica in patients over 60 years of age
Fracture/dislocation: usually history of trauma and sudden onset of pain.
NB osteoporotic patients.
Unexplained significant sensory or motor deficit
Rule out non MSK issues
–
Patient
visceral disease: any condition that irritates the mediastinal pleura, pericardium or diaphragm can cause
shoulder pain. Consider myocardial ischaemia
Primary Care
Secondary Care
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Impingement
Signs and Symptoms
Subacromial Impingement
Injection Advice
•
Pain on overhead activities and/or abduction.
•
Pain is more likely anterior shoulder and may radiate to the side of the arm.
•
A painful arc of movement- less pain on passive movement
•
Weakness due to pain usually in abduction and/or lateral rotation
•
Loss of movement at the affected shoulder
•
Shoulder pain at night
AC
•
•
•
•
joint Impingement
Injection Advice
Localised tenderness over AC joint
End range pain passively in all directions
Possible painful arc 150-180º
NB: Surgery rarely performed for AC joint dislocation
Impingement Referral Criteria
Primary care
•
Pain control Analgesia & NSAIDs as appropriate
•
Physiotherapy
•
Subacromial / AC joint steroid injection by appropriately trained GP or physiotherapist
Secondary care
•
Symptoms for 6-12 months.
•
Failure of conservative treatment (at least 2 steroid injections) and protracted course of physiotherapy.
•
X-Ray prior to referral +/- dynamic USS
•
Information to include when referring
–
–
–
–
–
Duration and any cause of symptoms
Indicate site/ spread of pain and if pain constant or intermittent, and/or waking at night
Indicate ROM (+/- painful arc)
Include treatment to date
XR results
Impingement Patient Information leaflet–Impingement
Patient
Primary Care
Secondary Care
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Adhesive Capsulitis
Signs and Symptoms
•
Active and passive reduced ROM, specifically loss of external (lateral) rotation, with normal XR (can be stiff in all
directions)
•
Pain can radiate to elbow/wrist
Self-limiting condition: highly variable in terms of presentation and duration
•
“Freezing" or painful stage, may last from six weeks to nine months, and in which the patient has a slow onset of
pain. As the pain worsens, the shoulder loses movement.
•
“Frozen" or adhesive stage is marked by a slow improvement in pain but the stiffness remains- can last from four to
nine months.
•
“Thawing" or recovery, when shoulder motion slowly returns towards normal- can last from 5 to 26 months
Adhesive Capsulitis Referral Criteria
Primary care
•
Reassure and advise to mobilise.
•
Pain control - Analgesia & NSAIDs as appropriate
•
Physiotherapy
•
Glenohumeral joint steroid injection by appropriately trained GP or physiotherapist (Up to three injections).
•
Self limiting condition
Secondary care
Only if failure to improve for 6-9 months.
•
Refer for distension arthrography / manipulation under anaesthetic/surgical release. (Consider referral sooner if
patient diabetic or has association with Dupuytren's and failure to respond to initial interventions)
•
Information to include when referring
–
–
–
–
–
Duration and any cause of symptoms
Indicate site/spread of pain and if pain constant or intermittent, and/or waking at night
Indicate ROM
Include treatment to date (injections/ physiotherapy)
XR results
Adhesive Capsulitis Patient Information leaflet– Adhesive Capsulitis
Patient
Primary Care
Secondary Care
Injection Advice
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Rotator Cuff Tears
Signs and Symptoms
•
•
•
•
•
•
Limited active range of movement, specifically during abduction
Sporadic worsening of pain, debilitation
Weakness, that is not due to pain, usually in abduction or lateral rotation
Atrophy of rotator cuff on looking at scapula musculature
Noticeable pain during rest
Crackling sensations or soft tissue crepitus when moving the shoulder
Rotator Cuff tears Referral Criteria
Primary care
•
•
•
Pain control - Analgesia & NSAIDs as appropriate
Subacromial steroid injection by appropriately trained GP or physiotherapist (Up to three)
Refer to physiotherapy
Secondary care
Consider referral for Surgical opinion if:
•
Younger patient with traumatic tear
•
Failure to improve with conservative treatment
•
USS prior to referral to confirm extent of tear/other pathology
•
Information to include when referring
–
–
–
–
–
Duration and any cause of symptoms
Indicate site/spread of pain and if pain constant or intermittent, and/or waking at night
Indicate ROM (active and passive)
Include treatment to date (injections/ physiotherapy)
XR /USS results (NB: RC tears findings on USS may be coincidental rather than causative)
Rotator Cuff tears Patient Information leaflet– Rotator Cuff Tears
Patient
Primary Care
Secondary Care
Injection Advice
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Instability/Recurrent Dislocation
Signs and Symptoms
•
•
•
•
History of dislocation / subluxation
Multi directional instability
Hypermobility
Pain
Instability/recurrent dislocation Referral Criteria
Primary care
•
•
Physiotherapy
Pain relief - Analgesia & NSAIDs as appropriate
Secondary care
•
•
•
Continuing shoulder instability despite prolonged course of Physiotherapy.
XR changes
Information to include when referring
–
–
–
–
–
–
Duration and any cause of symptoms
If recurrent dislocations – rough amount and frequency
Indicate site/spread of pain and if pain constant or intermittent, and/or waking at night
Indicate ROM loss/ excessive range
Include treatment to date (physiotherapy)
XR results
Instability/recurrent dislocation Patient Information leaflet– Instability/Recurrent Dislocation
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Patient
Primary Care
Secondary Care
Injection Advice Sub Acromial bursa
SAB injection used for impingement or rotator cuff
tears
posterolateral
•
•
•
•
•
•
Patient sits with arm hanging to distract joint
Identify lateral edge acromion
Aim for space under the acromion
Clean area with sterets/chloroprep
Can be given posteriorly, laterally or anteriorly
No more than 3 injections
•
40 mg Kenalog/5ml 1% lidocaine or up to 10 ml
0.5% Chirocaine into Sub Acromial Bursa
Blue, green or white needle depending on size of
patient
Deliver as bolus when no resistance felt (may
have to withdraw needle slightly)
•
anterior
•
anterolateral
•
NB: Physiotherapists must comply with PGD
Aftercare advice: relative rest 2 weeks- Pendular
exercises only, Avoid heavy lifting, repetitive
activities. Then commence mobilising and
strengthening exercises.
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Injection Advice – GH Joint
Glenohumeral joint for adhesive capsulitis
•
•
•
•
•
•
Patient sits with arm folded across waist to open up
posterior aspect GH joint space
Identify posterior angle acromion with thumb, and
coracoid process with index finger
Clean area with sterets/chloroprep
Insert needle below angle of acromion and push
obliquely anterior toward coracoid process
No more than 3 injections
•
•
Inject as bolus. No resistance to delivering solution
should be felt
40 mg (up to 80) Kenalog, 5 ml Lidocaine / 10 ml (up
to 20 ml) Chirocaine into GH joint
Blue or green needle depending on size of patient
Aftercare advice: relative rest 2 weeks- Pendular
exercises only, Avoid heavy lifting, repetitive
activities. Then commence mobilising and
strengthening exercises.
•
NB: Physiotherapists must comply with PGD
•
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Injection Advice – AC Joint
AC joint impingement/pain
•
•
•
•
•
Patient sits supported with arm hanging to distract joint
Identify edge of acromion, move medially to identify
AC joint.
Clean area with sterets/chloroprep
Insert needle angling medially at mid point of joint line.
No more than 3 injections
•
•
•
•
Inject as bolus
Up to 40 mg Kenalog/ 1 ml Lidocaine
Orange/blue needle
Aftercare advice: relative rest 2 weeks- Pendular
exercises only, Avoid heavy lifting, repetitive
activities.
Then commence mobilising and strengthening
exercises
NB: Physiotherapists must comply with PGD
Worthwhile tip: variability in obliquity of the AC joint,
therefore have x-ray on the screen to know how
obliquely to aim needle.
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Neck Pain / Neck with Arm Pain
Signs and Symptoms
•
•
•
Neck pain Common: two-thirds of the population have neck pain at some point in their lives.
More frequently seen in women than men.
Can range from mild discomfort to severe, burning pain with arm referral
Symptoms
•
•
•
•
•
•
•
General pain located in the neck area, as well as stiffness in the neck muscles.
May radiate to the shoulder or between the scapulae.
May radiate out into the arm, the hand or up into the head, causing a one-sided or double-sided headache.
Acute pain can give rise to torticollis.
May be weakness in the shoulders and arms.
May be altered sensation in the arms and fingers.
May have altered reflexes
Neck (and Arm) Pain Referral Guidelines
Primary care
•
•
•
•
•
GP treatment advice if no red flags present
Analgesia, NSAIDS
Muscle relaxant may be prescribed on a short-term basis of up to 1 to 2 weeks depending on progress.
Advise to keep moving
Refer to physiotherapy if symptoms persist
Secondary care: red flags
Neck pain Patient Information Leaflet- Neck pain
Patient
Primary Care
Secondary Care
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Click for Red Flags
Red Flags for Neck Pain – Immediate Referral to Neurosurgery
Serious underlying cause is more likely in
people presenting with:
•
New symptoms before the age of 20 years or
after the age of 55 years.
•
Weakness involving more than one myotome
or loss of sensation involving more than one
dermatome.
•
Intractable or increasing pain.
NB Index of suspicion as many patients will say
pain is increasing
Red flags suggesting possible malignancy,
infection or inflammation:
•
Fever
•
Unexplained loss of weight
•
History of inflammatory arthritis
•
History of malignancy, drug abuse, TB,
AIDS,or other infection
•
Immunosuppression
•
Pain that is increasing, unremitting and/or
disturbs sleep NB Index of suspicion as
many patients will say this
•
Lymphadenopathy
•
Exquisite localised tenderness over a
vertebral body
•
Dizziness, drop attacks
Patient
Primary Care
Secondary Care
Red flags suggesting myelopathy (compression of
the spinal cord):
• Insidious progression
• Gait disturbance; clumsy or weak hands; loss of
sexual/bladder/bowel function
• Lhermitte's sign (flexing the neck causes electric
shock-like sensations that extend down the spine
and shoot into the limbs)
• Upper motor neurone signs in the upper limbs
(hyperreflexia, Hoffman’s sign) and lower limbs
(hyperreflexia, clonus, spasticity, or positive
Babinski's sign - up-going plantar reflex)
• Lower motor neurone signs in the upper limbs
(atrophy, hyporeflexia, hyperrflexia)
• Variable sensory changes (loss of vibration and
joint position sense more evident in the hands than
in the feet)
Red flags suggesting severe trauma/skeletal injury:
• History of trauma
• Previous neck surgery
• Osteoporosis or risk factors for
• Increasing and/or unremitting pain
Red flags suggesting vascular insufficiency:
• Dizziness and blackouts (restriction of vertebral
artery) on movement, especially on extension of the
neck with upward gaze
• Dizziness, drop attacks
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Ankle & Foot Pain Information
Ankle
Osteochondral
lesion
Metatarsalgia
Differential
Diagnosis
Possible
Serious
Pathology
Indicators
History and
Examination
Ankle
Osteoarthritis
Morton’s
Neuroma
Plantarfasciitis
Ligament
Sprains
Tibialis
Posterior
Dysfunction
Impingement
Peroneal
Tendinitis
Patient Information
Leaflets
Ankle examination
Hallux
Rigidus
Hallux
Valgus
Achilles Tendinopathy/
Posterior heel pain
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Musculoskeletal – Foot and Ankle Patient Pathway
In all cases:
analgesia &
NSAIDs as
appropriate
Patient Presentation
Hallux valgus (Bunions)
• Lateral deviation of hallux
• Become symptomatic with ill-fitting shoes
• Bursitis forms over medial prominence, may ulcerate
• Secondary corns and callous
Primary Care
Orthopaedic Consultant Referral
• Education on footwear/
extra-width shoes
• Care of secondary lesions.
Refer?
•
•
•
•
Refer?
• Pain either due to pressure effects of the dorsal
osteophytes or degenerate joint
• Failure of conservative treatment
Refer?
• Failure of conservative treatment
• Fixed toe deformities
• Morton’s neuroma not responded to steroid injection
Refer?
Mainstay of treatment is conservative: if unsuccessful,
should be referred for surgical excision of bursa /
decompression of Achilles tendon
Refer?
• 80% self-limiting, resolving within 12-18 months
• Surgery is rarely indicated
Evidence base does not support use
of orthoses to limit progression
Hallux rigidus
• Inshoe orthoses/ rigid insoles/
rocker sole
• Intra-articular steroid injections
and/or mobilisation
• Degenerative osteo- arthritis of 1st MTP joint
• Pain during and following activities
• Restriction of movement in joint
• Dorsal exostosis
• Transfer metatarsalgia due to a stiff 1st MTJP
Metatarsalgia
General pain under metatarsals
• MTP joint synovitis/instability
• Intermetatarsal bursitis
• MTP joint arthritis
• Painful plantar callosities
Morton’s Neuroma
• Paroxysmal neuralgia affecting
web spaces and 2/3/4 toes
• Mainly a clinical diagnosis and
further investigations are done as
indicated.
April 2005
• Advice re footwear (avoid heels and
tight fitting shoes)
• Custom made orthoses
• Injection of steroid into the affected
interspace or MTP joint(s)
Pain should be the primary indication for surgery
Difficulty obtaining suitable shoes
Recurrent ulcers
Infection
Posterior Heel Pain
(i) Pump bumps
• Prominent posterior aspect of calcaneum (illustrated)
(ii) Achilles Tendinosis
• Tenderness/swelling proximal to insertion of tendon
to posterior calcaneum
(i) Simple padding and foot wear advice
(ii) - Stretching programme
- Heel raises/ inshoe orthoses
Plantar Heel Pain
(i) Plantar pad
• Fat pad atrophy with non-specific pain under heel
(ii) Plantar fasciitis
• Pain is worse on taking first steps in morning
• Tenderness at attachment of PF to medial calcaneal
tubercle (illustrated)
• Spurs are not significant and therefore X-rays are not indicated
Midfoot arthritis
(i) Heel cushions
(ii) - Regular calf/ plantar fascia
stretching
- In shoe orthoses
- Steroid injection
- Night splints
• Footwear modification
• Pain and stiffness
• Local tenderness
• Loss of medial longitudinal arch
• Acute injury – Rest, Ice, Compression
and Elevation (RICE)
• X-ray if fracture suspected
• Taping
• Proprioceptive/ balance exercises
• Semi rigid ankle orthoses reduce reoccurrence
Lateral ankle sprains
• Lateral ankle pain, swelling and giving way
Patient
Primary Care
Secondary Care
Refer?
• Surgical fusion is necessary if the orthotic
management is unsuccessful
Refer?
• No indication for surgery after acute ligament injuries
• Chronic pain and instability need further imaging and
may require surgical reconstruction
www.cci.scot.nhs.uk
Useful Information for Patients
www.patient.co.uk
Ankle and Foot
Possible Serious Pathology Indicators
Possible Serious Pathology
 Unusual deformity or effusion
 Signs of septic arthritis, fever, chills, hot, swollen joints
 Inability to weight bear due to pain
 Previous history of cancer or suspected malignancy
 Unremitting night pain
 Achilles tendon rupture - unable to calf raise, palpable gap in tendon, positive Thomson’s
test
Indicators that a more in depth history, clinical examination and investigations may
be required:
 Sudden onset of reduced range of motion, sensory or motor deficit without pain
 Neurovascular conditions, referral from the spine
 Inability to weight bear due to pain
Management
As appropriate
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Ankle
& Foot
Pain Informati
Return to Ankle and Foot
Pain
Information
Ankle and Foot Differential Diagnosis
Presentation
 Referral from the lumbar spine
 RA, tumour, septic arthritis, inflammatory condition
 Infection, coalition, neuropathy, stress fractures
Features Inflammatory arthritis
Consider previous episodes (Gout)
If other peripheral joints or spine affected: consider sero-negative arthritis
Spontaneous ankle or foot joint effusion, no history of trauma: refer to rheumatology
Specific Investigations:
FBC, CRP, PV; if acute attack: urate level
Management
As appropriate
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Ankle and Foot Pain History and Examination
History
 Age of patient, occupation and hobbies
 Symptoms, pain location, foot and ankle range of motion, weakness, numbness or altered sensation, giving way
or instability, locking, swelling,
 Onset of symptoms, injury, trauma,
 Pain location, intensity, duration, aggravating and easing factors, night pain, effect on ADLs/work
 History, PMH, systemic symptoms (fever, abdominal, cardiovascular), previous treatments/surgery, medication
Examination
Investigations as indicated
Observation
Radiographs
Posture, lower limb alignment, foot position, deformity,
swelling,
Radiographs (foot and ankle)
New onset of pain older than 50 years
Serious injury, osteoporosis, sensory or motor loss,
rheumatological disease
Painful foot deformity
Weight loss, past medical history of cancer, night pain,
fever longer than 48 hrs. Foot and/or ankle joint
effusion.
Palpation
Local areas of pain, medial and lateral ligaments, ankle
joint line, Achilles tendon
Range of Movement
Active and passive motion foot ankle dorsiflexion,
plantarflexion, inversion, eversion
Functional tests i.e. heel raise, squat, instability tests,
Neurovascular assessment if indicated
Consider when symptomatic measures have been
insufficient for patient’s symptoms:
Blood investigations: C-reactive protein, plasma
viscosity, FBC, U&Es, Liver function urate acid tests
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Ankle Impingement
Signs and Symptoms
•
•
•
•
Can be anterior or posterior impingement.
Bone spurs can either form on the end of the tibia, on the talus, or on both.
Local pain, usually following repetitive microtrauma, infection.
? Locking, giving way or catching at ankle.
Referral Criteria
Primary Care
•
•
•
•
•
Footwear modification.
Inshoe orthoses, (heel wedges) accommodation and padding
Pain medication Analgesia & NSAIDs as appropriate
Refer to podiatry or physiotherapy service
Steroid injection by appropriately trained GP/Physiotherapist and/or mobilisation
Primary Care Diagnostics
Radiographs: Ankle AP standing and lateral views, blood tests if inflammatory arthropathy
suspected
Secondary care
Failure of conservative treatment
Patient
Primary Care
Secondary Care
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Ankle Osteoarthritis
Signs and symptoms
•Can be talocrural, subtalar or midfoot
•Complain of swelling, catching, locking, Pain and stiffness
•Local tenderness
•Loss of medial longitudinal arch
•Reduced ability or increased pain on moving or weight bearing
Referral Criteria
Primary Care Management
•Advice regarding footwear, weight loss if appropriate, walking aids
•Analgesia & NSAIDs as appropriate
•Refer to podiatry/physiotherapy
Secondary Care Management
•Refer if no improvement in long term with persistent pain -?Surgical fusion required
•Radiographs prior to referral: Ankle AP standing and lateral views
Patient
Primary Care
Secondary Care
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Ankle Osteochondral Lesion
Sometimes called osteochondritis dessicans or osteochondral fractures
Signs and Symptoms
•Usually have a history of injury, single or repeated
•Pain may be diffuse or local and prolonged felt primarily at the lateral or medial
aspect of the ankle joint. Severe
•Swelling, catching and/or instability of the ankle joint.
•After an injury such as an ankle sprain, the initial pain and swelling should decrease
with appropriate recovery (PRICE).
•Persistent pain despite appropriate treatment after several months may raise
concern for an OLT. Diagnosis is one of suspicion, after ruling out other pathologies
Referral Criteria
Primary Care
• Immobilisation- Splinting/bracing- and restricted weight bearing
• Analgesia & NSAIDs as appropriate
• Refer Podiatry, Physiotherapy
Secondary Care
•
•
Refer if no improvement after 3 months (MRI or CT scan may be required)
XR prior to referral: Ankle AP standing and lateral views
Patient
Primary Care
Secondary Care
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Hallux Rigidus
Signs and Symptoms
•
Degenerative osteoarthritis of 1st MTP joint
•
Local tenderness and pain during and following activities
•
Restriction of movement in great toe
•
Dorsal exostosis
•
Transfer metatarsalgia due to a stiff 1st MTP Joint
•
Midfoot arthritis
•
Loss of medial longitudinal arch
Referral Criteria
Primary Care
•
Footwear modification: wear shoe with rigid sole, wide toe, avoid heels
•
Inshoe orthoses/ rigid insoles/ rocker sole: refer orthotics service
•
Analgesia & NSAIDs as appropriate
•
Refer to podiatry, physiotherapy service
•
Intra-articular steroid injections by appropriately trained GP/Podiatrist/Physiotherapist and/or
mobilisation
Secondary care
•
Pain either due to pressure effects of the dorsal osteophytes or degenerate joint
•
Failure of conservative treatment
•
Surgical joint replacement/fusion may be necessary if conservative management is unsuccessful
Hallux Rigidus Patient Information leaflet- Hallux Rigidus
Patient
Primary Care
Secondary Care
Injection Advice
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Hallux Valgus
Signs and Symptoms
•
•
•
•
•
•
•
•
•
•
33 per cent of people will develop hallux valgus at some stage in their lives - more common in females
Not all bunions are painful- can have large bunions without significant pain.
Becomes symptomatic with ill-fitting shoes
Deviating great toe can cause pressure on the second toe, resulting in the second hammer toe.
Irritated skin around the bunion – may ulcerate
Joint redness and pain – secondary corns and callous
Blisters may form more easily around the site of the bunion- sometimes becomes infected
Pain during walking and following activities
Restriction of movement in great toe joint
Can lead to mechanical function problem of the forefoot
Referral Criteria
Primary Care
•
•
•
•
•
•
Footwear modification: avoid high heels, pointed or tight fitting shoes.
Advise extra width shoes with laces or straps, as can be adjusted to the width of the foot.
Inshoe orthoses, accommodation and padding
Pain medication Analgesia & NSAIDs as appropriate
Intra-articular steroid injection by appropriately trained GP/Physiotherapist and/or mobilisation
Refer to podiatry or physiotherapy service
Secondary care
•
•
•
•
•
•
Pain either due to pressure effects or degenerate joint
Failure of conservative treatment
Surgical joint replacement/fusion may be necessary if conservative management is unsuccessful
Recurrent ulcers
Difficulty obtaining suitable shoes (orthotics)
Infection
Hallux Valgus Patient Information leaflet– Hallux Valgus
Patient
Primary Care
Secondary Care
Injection Advice
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Ligament Sprains
Signs and Symptoms
•
Lateral ankle pain - Can be acute or chronic, usually following an inversion injury
•
May complain of giving way, recurrent sprains, pain, stiffness, locking or swelling if chronic
Ligament sprains Referral Criteria
Primary care
• Acute injury – Protect, Rest, Ice, Compression and Elevation (PRICE)
• Analgesia & NSAIDs as appropriate
• Refer to Podiatry/ physiotherapy
• Taping
• Proprioceptive/ balance exercises
•
Semi rigid ankle orthoses may reduce recurrence
•
Imaging if appropriate: X-ray according to Ottawa rules
Ankle AP standing and lateral views
Secondary care
•
No indication for surgery after acute ligament injuries
•
Chronic pain and instability may need further imaging and may require surgical reconstruction
•
Refer if unable to weight bear
Ligament Sprains Patient Information leaflet – Ankle Ligament Sprain
Patient
Primary Care
Secondary Care
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Tibialis Posterior Dysfunction
Signs and Symptoms
•Adult acquired flat foot deformity, gradual onset.
•Can cause of mobility problems in older people.
•Medial foot and ankle pain, swelling around the medial hind foot.
•Lack of rear foot inversion on heel raise, flat longitudinal arch
•Pain that is worse with activity. High-intensity or high-impact activities, such as running, can be very difficult. Some
patients can have trouble walking or standing for a long time.
•Pain lateral ankle as foot collapses.
Referral Criteria Primary Care
• In the acute stage PRICE treatment should be followed
• Most patients can be treated without surgery, using orthotics
• Analgesia or NSAIDS if appropriate
• Podiatry in stages 1 and 2 (see guide)
Primary Care Diagnostics
• XR/Ultrasound scan
Secondary Care
•
Refer in stages 3 and 4 or if no improvement in stages 1 and 2 (see guide)
Patient
Primary Care
Secondary Care
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Classification Tibialis Posterior Dysfunction
Deformity
Physical Exam
Radiographs
Stage 1A
• Tenosynovitis
• No deformity
• Tendon normal length
• Symptoms are usually mild to
moderate.
• Pain and swelling are present on
the medial aspect of the foot.
• Mild weakness
• (+) single-leg toe raise
• Normal
Stage 11A
• Elongation or tearing of the tendon
• Flatfoot deformity
• Flexible hindfoot - subtalar joint
remains mobile.
• Normal forefoot
• (-) single-leg heel raise
• Mild sinus tarsi pain
• Arch collapse deformity
Stage 11B
• Flatfoot deformity
• Flexible hindfoot - subtalar joint
remains mobile.
• Secondary deformity as the midfoot
pronates and the forefoot abducts at
the transverse tarsal joint.
• Forefoot abduction ("too many toes",
>40% talonavicular uncoverage)
• (-) single-leg heel raise
• Severe sinus tarsi pain
• Arch collapse deformity
• Subtalar arthritis
Stage 111
• Flatfoot deformity
• Rigid forefoot abduction
• Rigid hindfoot valgus
• (-) single-leg heel raise
• Severe sinus tarsi pain
• Arch collapse deformity
• Subtalar arthritis
Stage 1V
•
•
•
•
• (-) single-leg heel raise
• Severe sinus tarsi pain
• Ankle pain
• Arch collapse deformity
• Talar tilt in ankle mortise
• Early degenerative changes
of the ankle - Subtalar
arthritis
Flatfoot deformity
Rigid forefoot abduction
Rigid hindfoot valgus
Deltoid ligament compromise
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Back to Tibialis Posterior Dysfunction
Peroneal tendinitis
Signs and symptoms
•
•
•
•
•
Common in runners or after repeated inversion injuries
Pain/swelling around the lateral malleolus, probably from a non-resolving sprain or
overuse.
May see the tendons subluxing behind the lateral malleolus.
Symptoms increase with activity and improve with rest.
May complain of instability.
Referral criteria Primary Care
• Advise PRICE if acute injury
• Analgesia & NSAIDs as appropriate
•If tendon not subluxing conservative management with podiatry or physiotherapy
Secondary Care
•
•
•
No indication for surgery
Chronic pain and instability may need further imaging: ultrasound scan
Refer if unable to weight bear
Patient
Primary Care
Secondary Care
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Plantar Heel Pain (Plantar Faciitis)
Signs and Symptoms
Plantar pad
•
Fat pad atrophy with non-specific pain under heel
•
•
•
Plantar fasciitis
Usually worse on initial weight bearing in the morning, better throughout the day and increasing in
the evening.
Electric shock pain, reduced sensation or pain at rest indicated possible neural entrapment or
lumbar spine referral.
Tenderness at attachment of PF to medial calcaneal tubercle
Plantar Heel Pain Referral Criteria
Primary care
•
Spurs are not significant and therefore X-rays are not indicated
•
Analgesia & NSAIDs as appropriate
•
Heel cushions
•
Regular calf/ plantar fascia stretching
•
- Off the shelf In shoe orthosis (From Boots/Allardyce/PhysioMed)
•
- Steroid injection by appropriately trained GP/Podiatrist/Physiotherapist
•
- Prescribed orthosis/Night splints: refer Orthotics
•
Refer podiatry, physiotherapy clinic
Secondary care
•
Not indicated
•
80% self-limiting, resolving within 12-18 months
•
Surgery is rarely indicated
Plantar Fasciitis Patient Information leaflet – Plantar Fasciitis
Injection Advice
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Secondary Care
Primary Care
Patient
Return to home page
Metatarsalgia
Signs and Symptoms Metatarsalgia
•
General pain under metatarsals
•
MTP joint synovitis/ instability
•
Intermetatarsal bursitis
•
MTP joint arthritis
•
Painful plantar callosities
Metatarsalgia Referral Criteria
• Primary care
• Advice re footwear (avoid heels and tight fitting shoes)
• Analgesia & NSAIDs as appropriate
• Refer to podiatry or physiotherapy
• Custom made orthosis
• ?Morton’s neuroma
Primary care diagnostics
• Radiographs if not settling. Foot AP standing, lateral and oblique views
Secondary care
•
Failure of conservative treatment. Refer if no improvement in long term with persistent pain and
deformity
•
Fixed toe deformities
•
No surgery indicated for cosmesis
Metatarsalgia Patient Information leaflet– Metatarsalgia
Patient
Primary Care
Secondary Care
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Morton’s Neuroma
Signs and Symptoms
• Paroxysmal neuralgia affecting web spaces and 2/3/4 toes
•
Pain and/or ‘clunk on Mulder’s test (squeeze midfoot joint)
•
Mainly a clinical diagnosis and further investigations are done as indicated.
Morton’s neuroma Referral Criteria
Primary care
• Advice re footwear (avoid heels and tight fitting shoes)
• Analgesia & NSAIDs as appropriate
• Refer to podiatry or physiotherapy
• USS to establish size of neuroma and confirm diagnosis
• Injection of steroid into the affected interspace or MTP joint(s) by appropriately trained
GP/Podiatrist/Physiotherapist - palpate for painful area
Secondary care
• Failure of conservative treatment
• Morton’s neuroma not responded to steroid injection
• USS shows neuroma greater than 8 mm
Morton’s Neuroma Patient Information Leaflet– Morton’s Neuroma
Injection Advice
Patient
Primary Care
Secondary Care
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Achilles Tendinopathy/Posterior Heel Pain
Signs and Symptoms
•
Pump bumps
Prominent posterior aspect of calcaneum
•
•
•
Achilles Tendinosis
Tenderness/swelling proximal to insertion of tendon to posterior calcaneum
Pain on activity, easing during activity or with rest
May be related to change of activity, footwear or orthotics
Achilles Tendinosis/Posterior Heel Pain Referral Criteria
Primary care
•
Simple padding and foot wear advice (Avoid low heeled footwear. Avoid boots or sports shoes which may
impinge on the painful area during activity )
•
Analgesia & NSAIDs as appropriate
•
Stretching programme
•
Off the shelf heel raises/ inshoe orthoses (From Boots/Allardyce/PhysioMed)
•
Refer podiatry or physiotherapy
Mainstay of treatment is conservative
•
USS to determine tendinosis stage if considering steroid injection
•
Injection (should not be offered without USS to determine tendon state) NB: Steroid to be used under
caution and no more than 2-3
Secondary care
•
Usually not indicated. Surgery rarely indicated.
Achilles Tendinosis/Posterior Heel Pain Patient Information leaflet– Achilles tendinosis
Patient
Primary Care
Secondary Care
Injection Advice
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Injection Advice Hallux Rigidus/Valgus
Hallux Rigidus / Hallux Valgus
•
•
•
•
•
•
•
•
NB: Physiotherapists must comply with PGD
Patient lies with foot supported
Identify joint line and distract toe
Insert needle perpendicularly avoiding
extensor tendons
Up to 3 injections
Up to 40mg Kenalog/2ml Lidocaine into
painful area.
Blue/orange needle
Delivered as bolus
Aftercare advice: avoid excessive WB 1-2
weeks
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Injection Advice Plantar Fasciitis
Plantar Fasciitis
•
Patient lies prone with foot in dorsiflexion
•
Identity tender area on heel
•
Clean area with sterets/chloroprep
•
Insert needle perpendicularly into medial sole
distal to heel pad. Advance at 45° toward medial
tubercle on the calcaneus until touching bone
•
Up to 3 injections
•
Up to 40 mg Kenalog 2ml Lidocaine
•
Green needle
•
Peppering technique into fascia at medial
bony origin
•
Aftercare advice: relative rest 2 weeks, then
fascial stretching exercises
•
Address causative factors including weight loss
if appropriate
NB: Physiotherapists must comply with PGD
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Injection Advice Achilles Tendinopathy
Achilles Tendinopathy
NB: local agreement- some health boards do not
inject Achilles tendinopathy
NB steroid to be used under caution
•
NB Must USS first!!!! To determine tendon state
•
Patient lies prone with foot in dorsiflexion over end
of bed.
•
Identify area of tenderness
•
Bend needle slightly using needle sheath
•
Clean area with sterets/chloroprep
•
Insert needle on medial side, angle parallel to
tendon, deposit half solution while withdrawing
needle
•
Change needle
•
Repeat procedure on lateral side
•
•
•
•
•
Up to 20 mg Kenalog, 1.5 ml Lidocaine each
side of tendon
Green needle
Deliver as Bolus
No resistance should be felt - DO NOT inject
into body of tendon
Aftercare advice: Absolute avoidance of
overuse 10-14 days (WB tendon, predisposed to
rupture)
NB: Physiotherapists must comply with PGD
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Injection Advice Morton’s Neuroma
Morton’s Neuroma
Technique
• Patient lies with knees bent and foot supported
• Identify painful area
• Clean area with sterets/chloroprep
• Insert needle 45° angle
• Up to 2 injections
•
•
•
•
Up to 40mg Kenalog/4ml Lidocaine into painful
area.
Blue/Green needle
Delivered as bolus
Aftercare advice: relative rest 1-2 weeks
•
NB: Physiotherapists must comply with PGD
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General Injection Advice
Elbow
Tennis Elbow
Golfer’s Elbow
Shoulder
Glenohumeral joint
AC joint
Subacromial bursa
Hip
Trochanteric Bursa
Tendinopathies
Hand
De Quervains
Trigger finger
OA 1ST CMC joint
Foot
Hallux problems
Morton's Neuroma
Plantar Fasciitis
Achilles Tendinosis
Injection Handout
March 2012
Knee
Knee Joint
Injection Patient
Information
Leaflet
Ref:
Kesson, Atkins and Davies,2003: Musculoskeletal Injection Skills. Butterworth Heinmann
Injection Techniques in Orthopaedic Medicine, Saunders and Longworth. Churchill Livingstone 2006
Please note: these are guidelines for GPs. AHPs must comply with PGD
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Patient Information Leaflets
Shoulder
Elbow
Hand
Hip
Knee
Ankle/Foot
Cervical Spine
Lumbar Spine
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Shoulder
•
•
•
•
•
•
NHS Inform: General advice acute pain
PRICE Guidelines
Impingement
Adhesive Capsulitis
Rotator Cuff Tears
Instability/Recurrent Dislocation
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Return to Patient Information Leaflets
Return to Shoulder Pain Information
Elbow
•
•
•
•
•
•
NHS Inform: General advice acute pain
PRICE Guidelines
NHS Inform Elbow (PhysioTools)
Tennis Elbow
Golfers Elbow
General Elbow Stiffness
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Return to Patient Information Leaflets
Return to Elbow Pain Information
Hand
• NHS Inform: Acute Wrist/Hand/Finger Pain
Advice
• PRICE Guidelines
• Trigger Finger
• De Quervain's
• Dupuytren's
• Ganglia
• OA CMC joint
• Carpal Tunnel
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• Cubital Tunnel
Return to Patient Information Leaflets
Return to Hand Pain Information
Hip
•
•
•
•
•
•
NHS Inform: Acute Hip Pain Advice
NHS Inform: Acute Thigh Problem Advice
PRICE Guidelines
Trochanteric Bursitis
OA Hip
Tendonopathy
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Return to Patient Information Leaflets
Return to Hip Pain Information
Knee
•
•
•
•
•
•
•
•
NHS Inform: Acute Knee Pain Advice
NHS Inform: Acute Calf Pain Advice
PRICE Guidelines
Anterior Knee Pain
OA Knee
Meniscal problems
Ligament Sprains/Strains
Bursitis
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Return to Patient Information Leaflets
Return to Knee Pain Information
Ankle/Foot
•
•
•
•
•
•
•
•
•
•
NHS Inform: Acute Ankle Pain Advice
NHS Inform: Acute Foot Pain Advice
PRICE Guidelines
Ankle Ligament Sprain
Metatarsalgia
Morton’s Neuroma
Achilles tendinosis
Hallux Valgus
Hallux Rigidus
Plantar Fasciitis
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Return to Patient Information Leaflets
Return to Ankle/Foot Pain Guidelines
Cervical Spine
• NHS Inform: Acute Neck Pain advice
• NHS Inform: Whiplash
• Hints and Tips to Help you Manage your
Neck (NHS Tayside)
• NHS Inform Neck (PhysioTools)
• NHS Inform Neck (Video Physio)
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Return to Patient Information Leaflets
Return to Neck Pain Information
Lumbar Spine
• NHS Inform Back in Control
• NHS Inform Back Problems
• Hints and Tips to Help you Manage your
Back (NHS Tayside)
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Return to Patient Information Leaflets
Return to LBP Pathway
Glossary/Description tests
•
•
•
•
•
•
Lhermitte’s sign: suggests a lesion of the dorsal columns of the cervical cord
or MS. Neck flexion produces sudden general electric shock feelings down
arms/spine/legs.
Return to red flags LBP or neck pain
Hoffman's sign: indicates presence upper motor neuron lesion from spinal
cord compression. Flexion and sudden release of the terminal phalanx of the
middle finger results in reflex flexion of the thumb and index (Possibly all
digits)
Return to red flags LBP or neck pain
- positioning the neck in extension (sometimes flexion) may worsen reflex
Babinski reflex: can indicate upper motor neuron lesion. Stroke lateral side
of sole of foot from heel up to base 5th metatarsal, then across metatarsal
heads firmly. Positive if great toe extends and other toes fan out.
Return to red flags LBP or neck pain
Tinel’s test: detects irritated nerves. Tap over nerve (Positive if produces
tingling/pain)
Return to CTS or Cubital Tunnel
Phalen’s test: Patient pushes the dorsal surfaces of both hands together for
30–60 seconds (Positive if produces tingling/pain).
Return to CTS
Finklestein’s test: indicates De Quervain’s. Wrap patient’s fingers around
thumb then pull wrist into ulnar deviation. Positive if produces pain
Return to De Quervain’s
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Glossary/Description tests
•
Osmond Clark test: apply an inferior glide to the patella while the patient actively
contracts quads. Pain could indicate patellofemoral joint dysfunction
•
Anterior drawer test: used to assess ACL laxity. Patient lies supine with the hip flexed
to 45° and knee to 90°. The examiner sits on the plinth at patient’s foot to prevent foot
slipping. Grasp the tibia just below knee joint line. The thumbs are placed in the ‘eyes of
the knee’ on either side of the patellar tendon. The index fingers should palpate
hamstring tendons to ensure that they are relaxed. The tibia is then drawn forward
anteriorly. An ACL-deficient knee will demonstrate increased forward translation of the
tibia at the conclusion of the movement
•
Lachman’s test: used to assess ACL laxity. Flex knee to 30°, one hand above joint line,
preventing forward movement of femur, one hand behind knee. Examiner pulls tibia assess the amount of anterior motion of the tibia in comparison to the femur. An ACLdeficient knee will demonstrate increased forward translation of the tibia at end of
movement.
•
Ober’s manoeuvre: patient lies on side with hips and knees flexed. The upper leg is
passively extended then lowered to the plinth. Lateral hip pain or considerable tightness
may indicate iliotibial band syndrome.
•
Thomson test: patient should lie face-down, feet extended farther than end of the bed.
The examiner squeezes the calf muscle. in normal patient this should cause the toes to
point downward as the Achilles pulls the foot. In a patient with a ruptured Achilles
tendon, the foot will not move. That is a positive Thompson test.
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Glossary/Description Meniscal
tests
•
McMurray’s test: used to evaluate for meniscal injury. The patient is supine, and the
knee flexed fully. One hand holds ankle, other hand holds knee, with thumb on the
lateral joint line and index finger on the medial joint line to palpate crepitus/click.
Positive if ‘pop’ or ‘snap’ felt at the joint line
–
–
Medial meniscus assessment: Apply valgus stress to flexed knee. Externally rotate leg (toes
point outward) Slowly extend the knee while still in valgus. If pain or a "click" is felt, this
constitutes a "positive McMurray test" for a tear in the medial meniscus.
Lateral meniscus: Repeat above with varus stress and internal rotation
•
Steinman's test: used to evaluate for meniscal injury. Patient sits on the edge of the
plinth, with knee hanging at 90° flexion, or the patient is supine with the knee at 90°
flexion. Rotate tibia laterally then medially. Test is positive if lateral pain is elicited on
medial rotation and medial pain is elicited on lateral rotation. Repeat test in various
degrees of knee flexion.
•
Thessaly test: used to evaluate for meniscal injury. Patient stands flatfooted on the
floor. Support the patient by holding outstretched hands. The patient rotates knee and
body, internally and externally, three times, keeping the knee in slight (5°) flexion.
Repeat with the knee flexed to 20°.
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